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Kode Puskesmas :

Puskesmas :
Kecamatan : TAHUNAN
Puskesmas Pembantu yg Ada ……………. TAHUN : 2019
Kabupaten : MALUKU BARAT DAYA
Provinsi : MALUKU
LAPORAN PEMAKAIAN DAN LEMBAR PERMINTAAN OBAT (LPLPO)

Total Harga Total Harga Total Harga


KODE/N STOK Kadaluwarsa/R STOK Harga Kadaluwarsa/R
NAMA OBAT dan PERBEKALAN KESEHATAN SATUAN PENERIMAAN PERSEDIAAN PEMAKAIAN SISA STOK PERMINTAAN Penerimaan Pemakaian Sisa Stock KET
O. URT AWAL usak APT Satuan (Rp) usak (Rp)
(Rp) (Rp) (Rp)

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
1 Alat Suntik Sekali Pakai 1 CC Buah - 100 100 - - 100 - 1,100 110,000 - - 8,580,000
2 Alat Suntik Sekali Pakai 2,5 CC Buah - 100 100 - - 100 - 1,750 175,000 - - 175,000
3 Alat Suntik Sekali Pakai 3 CC Buah - 100 100 100 - - 500 779 77,900 77,900 - 389,500
4 Alat Suntik Sekali Pakai 5 CC Buah - - - 25 500 (525) - 968 - 24,200 484,000 6,921,200
5 Alat Suntik Sekali Pakai 10 CC Buah - - - 15 185 (200) - 1,375 - 20,625 254,375 2,433,750
6 Alat Suntik Sekali Pakai 20 CC Buah - - - - - - - 1,500 - - - -
7 Abocath ( I.V. Catheter) No. 18 Buah - 50 50 - - 50 50 3,800 190,000 - - 190,000
8 Abocath (I.V.Catheter) No.20 Buah - 50 50 - - 50 50 3,800 190,000 - - 5,510,000
9 Abocath (I.V.Catheter) No.22 Buah - 50 50 3 - 47 50 3,800 190,000 11,400 - 6,828,600
10 Abocath (I.V.Catheter) No.24 Buah - 50 50 3 - 47 50 3,800 190,000 11,400 - 5,498,600
11 Abocath (I.V.Catheter) No.26 Buah - - - - - - 50 4,100 - - - -
12 Albendasol Tab 400 mg Tablet - - - - - - - 492 - - - -
13 Alkohol 70 % 1000 ml ( Etanol ) Botol - 26 26 9 - 17 - 25,000 650,000 225,000 - 6,875,000
14 Alkohol 70 % 100 ml ( Etanol ) Botol - - - - - - 50 - - - -
15 Allopurinol Tab 100 mg Tablet - - - 620 - (620) - - - - -
16 Allopurinol Tab 300 mg Tablet - - - - - - - 108 - - - -
17 Ambroxol sirup 15 mg/ml Botol - 6 6 21 - (15) 200 6,095 36,570 127,995 - 371,795
18 Ambroxol Tab 30 mg Tablet - 200 200 2,138 - (1,938) 1,500 201 40,200 429,738 - 5,637,849
19 Aminofillin inj 24 mg/ml-10 ml Ampul - - - - - - 50 3,280 - - - -
20 Aminofilin Tab 200 mg Tablet - - - - - - - 107 - - - 160,500
21 Amoxicillin Kaplet 250 mg Kaplet - 5,000 5,000 2,840 - 2,160 3,000 212 1,060,000 602,080 - 7,966,960
22 Amoxicillin Kapsul 500 mg Kapsul - 6,000 6,000 4,087 - 1,913 - 245 1,470,000 1,001,315 - 2,864,785
23 Amoxicillin Sirup Kering 125 mg/ 5 ml Botol - - - 79 - (79) 100 2,790 - 220,410 - 3,361,950
24 Ampisillin Kaplet 250 mg Kaplet - - - - - - - - - - -
25 Ampisillin Kaplet 500 mg Kaplet - - - 1,646 - (1,646) 1,000 450 - 740,700 - 6,505,200
26 Ampisillin Serbuk Inj 1.m/ i.v 1000 mg/ml Vial - - - - - - 100 10,296 - - - -
27 Ampisillin sirup Kering 125 mg/ 5 ml Botol - - - - - - - - - - -
28 Amlodipin 5 mg tablet tablet - 500 500 355 - 145 500 99 49,500 35,145 - 2,821,500
29 Amlodipin 10 mg Tablet - - - - - - - 83 - - - -
30 Anvomer B6 Tab Tablet - - - - - - - 3,987 - - - -
31 Antasida Doen Tab Kombinasi Tablet - 300 300 3,493 - (3,193) - 58 17,400 202,594 - 5,510,696
32 Antasida Doen II Suspensi Botol - - - 19 - (19) 200 2,257 - 42,883 - 15,799

33 Anti Fungi Doen Kombinasi (Asam Bensoat 3%+As.Salisilat 6% - - - 22 - (22) - 5,620 - 123,640 - 11,841,340
(Whitefield) Tube
34 Anti Malaria Doen Kombinasi (DHP) Tablet - - - - - - - 2,070 - - - -
35 Aquadest Steril (Air Untuk Injeksi Ampul 25 ml) Ampul - - - - - - 1,000 2,798 - - - -
36 Artemeter injeksi 80 mg/ml Ampul - - - - - - - 26,600 - - - 5,586,000
37 Artesunat Injeksi Ampul - - - - - - - 48,750 - - - -
38 Asam Salisilat 2% + Belerang Endap 4% ( salf 2-4 ) Tube - - - 17 - (17) - 3,274 - 55,658 - 1,145,900
39 Asam Askorbat ( Vit C ) Tab 50 mg Tablet - 3,000 3,000 1,254 - 1,746 - 131 393,000 164,274 - 2,390,226
40 Asam Folat Tab 1 mg Tablet - - - 290 - (290) - 88 - 25,520 - 467,280
41 Asam Mefenamat Kapsul 250 mg Kaplet - - - - - - - - - - -
42 Asam Mefenamat Kaplet 500 mg Kaplet - 1,500 1,500 4,968 - (3,468) 1,500 195 292,500 968,760 - 2,421,120
43 Asam Traneksamat injeksi 100 mg/ml Ampul - - - - - - 50 2,798 - - - -
44 Aspar - K Tab Tablet - - - - - - - 4,312 - - - -
45 Atropina Sulfat Inj 0,25 mg/ml-1ml Ampul - - - - - - 50 1,914 - - - -
46 ATS Injeksi 1500 IU Ampul - - - - - - - 43,183 - - - -

LPLPO/KAB MBD Page 1


1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
47 Asiklovir Krim 5 % Tube - - - - - - 250 4,383 - - - -
48 Asiklovir Tab 200 mg Tablet - - - - - - - 236 - - - -
49 Asiklovir Tab 400 mg Tablet - - - 219 - (219) 1,400 414 - 90,666 - 2,292,318
50 Bedak Salysil Serbuk 2 % Dus - - - - - - 70 1,142 - - - -
51 Benzatin Bensil Penisillin 1,2 Juta IU Vial - - - - - - 50 - - - -

52 Bessi II Sulfat Tab Kombinasi : Besi II sulfat 7H2O 200 mg, Asam Tablet - 3,000 3,000 1,530 - 1,470 2,000 445 1,335,000 680,850 - 8,014,450
Folat 0,25 mg (Fe = Tambah Darah)
53 Betametason 0,1% Krim Tube - - - 21 - (21) 100 1,520 - 31,920 - 1,238,800
54 Bisoprolol tab Tablet - - - - - - 1,000 - - - -
55 Bioplasenton gel Tube - - - 2 - (2) 150 17,928 - 35,856 - -
56 Buscopan Injeksi Ampul - - - - - - 50 - - - -
57 Bufacetin Salep Kulit Krim Tube - - - - - - - 4,024 - - - -
58 Captopril Tablet 12,5 mg Tablet - - - 710 - (710) - 87 - 61,770 - 2,079,822
59 Captopril Tablet 25 mg Tablet - - - - - - - 86 - - - -
60 Catgut Chromic + Jarum No. 2/0 75 cm Pcs - 24 24 - - 24 10 5,583 133,992 - - 133,992
61 Catgut Chromic + Jarum No. 3/0 75 cm Pcs - 24 24 - - 24 10 5,583 133,992 - - 133,992
62 Catgut Plain + Jarum No.2/0 75 cm Pcs - 24 24 - - 24 10 5,583 133,992 - - 2,009,880
63 Catgut Plain + Jarum No. 3/0 75 cm Pcs - 24 24 - - 24 10 5,583 133,992 - - 133,992
64 Catapres Injeksi Ampul - - - - - - 10 97,220 - - - -
65 Chloramfeniramine Maleat (Ctm) Tablet - 2,000 2,000 5,434 - (3,434) 4,000 26 52,000 141,284 - 872,430
66 Chloramfenikol Kapsul 250 mg Kapsul - - - 986 - (986) - 357 - 352,002 - 16,055,004
67 Chloramfenikol Kapsul 500 mg Kapsul - - - - - - - - - - -
68 Chloramfenikol Salf Mata 1% Tube - - - 34 - (34) 130 2,160 - 73,440 - 2,162,160
69 Chloramfenikol Suspensi 125 mg/5 ml Botol - - - 20 - (20) - - - - -
70 Chloramfenikol Tetes Telinga 3 % Botol - - - - - - 60 2,590 - - - -
71 Chloramfenikol Salep Kulit 2 % Tube - - - - - - 50 4,042 - - - -
72 Clindamiciyn 150 mg Kapsul - - - - - - - 720 - - - 3,600,000
73 Clindamicin 300 mg Kapsul - - - - - - - 893 - - - -
74 Cotrimoxasol Suspensi Botol - - - 17 97 (114) - 2,155 - 36,635 209,035 881,395

75 Cotrimoxasol Tab kombinasi : Sulfametoksazole 400mg , Tablet - - - 476 - (476) 1,000 132 - 62,832 - 6,788,760
Trimetroprim 80 mg
76 Dexamethason Inj 5 mg/ml-1 ml Vial - 100 100 100 - - 100 1,378 137,800 137,800 - 1,102,400
77 Dexamethason Tab 0,5 mg Tablet - 300 300 1,447 - (1,147) 2,000 37 11,100 53,539 - 696,858
78 Diazepam Inj 5mg/ml-2ml Ampul - - - - - - - 2,150 - - - 645,000
79 Diazepam Tab 2 mg Tablet - - - - - - - 86 - - - -
80 Diazepam Tab 5 mg Tablet - - - 74 - (74) - 115 - 8,510 - 287,270
81 Difenhidramin HCL Inj 10 mg/ml-1 ml Vial - 100 100 - - 100 50 1,373 137,300 - - 137,300
82 Digoxin Tab 0,25 mg Tablet - - - - - - 300 104 - - - 364,000
83 Dimenhidrinat Tablet 50 mg Tablet - - - - 800 (800) 1,000 - - - -
84 Doksisiklik Kapsul 100 mg Kapsul - - - - - - - 264 - - - -
85 Domperidon Tab 10 mg Tablet - - - 137 - (137) - 190 - 26,030 - 1,621,270
86 Dulcolax Tab Tablet - - - - - - 1,100 166 - - - -
87 Dulcolax Suppos Suppos - - - - - - 100 36,200 - - - -
88 Diltiasem HCL Tab 30 mg Tablet - - - - - - - 153 - - - -
89 Efedrin HCL ( Efedrina ) Tab 25 mg Tablet - - - - - - 200 - - - -
90 Elastic Verband 4 Inchi Buah - - - - - - 20 30,250 - - - 3,025,000
91 Elastic Verband 6 Inchi Buah - - - - - - 10 - - - -
92 Erlamycetin Tetes Telinga Botol - - - - - - 70 5,658 - - - -
93 Epinefrin HCL / Bitartrat ( Adrenalin ) Inj. 0,1%-1ml Ampul - - - - - - 150 2,486 - - - -
94 ErLamycetin Tetes Mata Botol - - - 2 - (2) 60 8,183 - 16,366 - 73,647
95 Eritr0misin Kapsul 250 mg Kapsul - - - - - - - 693 - - - -
96 Eritromisin Kapsul 500 mg Kapsul - - - 37 - (37) - 704 - 26,048 - 1,753,664
97 Eritromisin Sirup 200 mg/5 ml Botol - - - 26 4 (30) - 6,788 - 176,488 27,152 6,699,756
98 Etil Klorida Spray Botol - - - - - - - - - - -
99 Etambutol HCL ( Etambutol ) Tab 250 mg Tablet - - - - - - 100 - - - -
100 Extension Tube Pcs - - - - - - - - - - -
101 Eugenol cairan Botol - - - - - - 20 20,000 - - - -
102 Fenobarbital Inj 50 mg/ml-2ml vial - - - - - - 20 2,325 - - - -
103 Fenobarbital Tab 30 mg Tablet - - - - 2,400 (2,400) - 243 - - 583,200 1,749,600

LPLPO/KAB MBD Page 2


1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
104 Fenol Gliseron tetes telinga 10 % Botol - 34 34 5 - 29 10 2,590 88,060 12,950 - 202,020
105 Fitomenadion ( Vit K1 ) Inj 10 mg/ml-1ml Vial - - - - 90 (90) 50 4,438 - - 399,420 1,198,260
106 Fitomenadion ( Vit K1 ) Tab Salut 10 mg Tablet - - - - - - - 890 - - - 49,141,350
107 Foley Catheter T. 6 Botol - - - - - - 10 30,000 - - - -
108 Foley Catheter T. 8 Buah - 10 10 - - 10 10 30,000 300,000 - - 300,000
109 Foley Catheter T.10 Buah - 10 10 - - 10 10 30,000 300,000 - - 300,000
110 Foley Catheter T.12 Buah - 10 10 - - 10 10 8,000 80,000 - - 80,000
111 Foley Catheter T.14 Buah - 10 10 - - 10 10 8,000 80,000 - - 80,000
112 Foley Catheter T. 16 Buah - 10 10 - - 10 10 8,000 80,000 - - 80,000
113 Foley Catheter T.18 Buah - 10 10 - - 10 10 8,000 80,000 - - 80,000
114 Foley Catheter T. 20 Buah - 10 10 - - 10 10 8,000 80,000 - - 80,000
115 Foley Catheter T. 22 Buah - 10 10 - - 10 10 8,000 80,000 - - 80,000
116 Foley Catheter T. 24 Buah - 10 10 - - 10 10 8,000 80,000 - - 80,000
117 Flagystatin Tablet Vagina Tablet - - - - - - 30 29,520 - - - -
118 Furosemida Inj i.v i.m 10 mg/ml Vial - - - - - - 50 1,850 - - - -
119 Furosemida Tab 40 mg Tablet - - - 87 - (87) - 88 - 7,656 - 278,256
120 Formalin Cairan Botol - - - - - - 15 - - - -
121 Gentamisin Inj 80 mg/ 2ml Ampul - - - - - - 30 3,854 - - - -
122 Gentamisin Salf Kulit 0,1 % Tube - - - 20 - (20) - - - - -
123 Gentamisin Slufat Tetes Mata 0,3 % Botol - - - - - - 60 5,020 - - - -
124 Glimepride Tab 4 mg Tablet - - - - - - 1,000 273 - - - -
125 Gentian Violet Larutan 1 % Botol - - - 4 - (4) - 5,200 - 20,800 - 852,800
126 Gipsonal Gipsum 4 Inchi Buah - - - - - - 10 28,500 - - - -
127 Gipsonal Gipsum 6 Inchi Buah - - - - - - 10 37,500 - - - -
128 Glibenclamide Tab Tablet - - - 10 - (10) - 720 - 7,200 - 5,342,400
129 Gliseril Guaiakolat Tab 100 mg/ Guafenisine Tablet - 100 100 6,215 - (6,115) 1,000 132 13,200 820,380 - 8,286,168
130 Glukosa Larutan Infus 5 % Steril Botol - 60 60 20 20 20 72 6,900 414,000 138,000 138,000 1,876,800
131 Glukosa Larutan Infus 10 % Steril Botol - - - - - - - 6,840 - - - -
132 Glukosa Larutan Infus 40 % Steril Botol - - - - - - - - - - -
133 Griseovulvin Tab 125 mg, Micronized Tablet - 2,000 2,000 106 - 1,894 - 242 484,000 25,652 - 4,712,224
134 Handscoen S Pcs - - - - - - - - - - -
135 Handscoen M Pcs - 200 200 - - 200 200 - - - -
136 Handscoen L Pcs - 200 200 - - 200 300 - - - -
137 Handscoen No. 6 Pcs - - - - - - - - - - -
138 Handscoen No.7 Pcs - 100 100 - - 100 100 6,985 698,500 - - 698,500
139 Handscoen No.7,5 Pcs - 100 100 - - 100 100 6,985 698,500 - - 698,500
140 Hidroklorotiasida ( HCT ) Tab 25 mg Tablet - - - - - - - 194 - - - -
141 Hidrokortison Krim 2,5 mg Tube - - - 27 - (27) - 2,846 - 76,842 - 3,045,220
142 Ibuprofen Suspensi Botol - 100 100 8 - 92 100 5,739 573,900 45,912 - 527,988
143 Ibuprofen Tab 200 mg Tablet - - - - - - - - - - -
144 Ibuprofen Tab 400 mg Tablet - - - - - - 1,000 - - - -
145 Infusion Set Anak Pcs - 200 200 50 150 - 150 3,500 700,000 175,000 525,000 3,850,000
146 Infusion Set Dewasa Pcs - - - 80 10 (90) - 3,200 - 256,000 32,000 2,720,000
147 Isoniasid ( INH ) Tab 100 mg Tablet - - - - - - - - - - -
148 Isoniasid ( INH ) Tab 300 mg Tablet - - - - - - - 165 - - - -
149 Isosorbid Dinitrat Tab Sublingual 5 mg Tablet - - - - - - 100 - - - -
150 Kalium Glukonat injeksi 10% (100mg/ml) Ampul - - - - - - 50 7,800 - - - -
151 Kalsium Laktat ( Kalk ) Tab 500 mg Tablet - 2,320 2,320 705 - 1,615 - 62 143,840 43,710 - 1,011,592
152 Karbamasepin Tab 200 mg Tablet - - - - - - - 241 - - - -
KAEN-3B Larutan infus (mengandung NaCl 1,75+KCL 1,5gr+ Na
153 Lactat 2,24 gr, Dextrose 27 gr) Botol - - - - - - 108 23,500 - - - -

154 Kapas Putih 1000 gr (Kapas Putih 1 Kg) Roll - 2 2 1 - 1 6 - - - -


155 Kantung Darah 250 cc Roll - - - - - - - - - - -
156 Kapas Pembalut Absorben 250 Gram Roll - - - - - - 10 22,000 - - - -
157 Kapas Berlemak 500 mg Buah - - - 4 - (4) - 16,500 - 66,000 - 1,105,500
158 Kasa Roll Panjang Besar 40x80 Cm Buah - 4 4 2 - 2 4 105,000 420,000 210,000 - 2,625,000
159 Kasa Kompres 40/40 Steril Buah - 400 400 225 - 175 - 1,600 640,000 360,000 - 2,200,000
160 Kasa Pembalut Hidrofil Steril 16 cm x 16 cm Buah - 10 10 - - 10 - 8,000 80,000 - - 80,000
161 Kasa Pembalut Hidrofil Supergrade 40 cm x 16 cm Buah - - - 6 - (6) - 36,960 - 221,760 - 147,840

LPLPO/KAB MBD Page 3


1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
162 Kasa Steril 10 cm x 10 cm Buah - - - - - - - - - - -
163 Keterolac Inj 30 mg Ampul - - - - - - 100 1,265 - - - -
164 Ketokonazole Tab 200 mg Tablet - - - 220 - (220) - 311 - 68,420 - 3,819,080
165 Ketokonazole Krim Tube - - - 44 - (44) - 2,893 - 127,292 - 1,455,179
166 Kinina Dihidroklorida ( Kina ) Inj 25 %-2ml Ampul - - - - - - - 7,440 - - - -
167 Kuinin Sulfat Tab 222 mg ( H2O ) (Qunine 222 mg) Tablet - - - - - - - 799 - - - 5,596,196
168 Klorpromasin HCL Tab Salut 25 mg Tablet - - - - - - - - - - -
169 Klorpromasin HCL Tab Salut 100 mg Tablet - - - - - - - 179 - - - 358,000
170 Klorpromasin Inj 25 mg/ml-1ml Ampul - - - - - - - 1,550 - - - -
171 Klorpromasin Inj 5 mg/ ml-2ml Ampul - - - - - - - - - - -
172 Kodein HCL ( Kodeina ) Tab 10 mg Tablet - - - - - - - 600 - - - -
173 Klip Plastik 7 x 10 cm Pak - - - - - - 7,000 - - - -
174 Klip Plastik 8 x 5 cm Pak - - - - - - 7,000 - - - -
175 Kertas pulvis Pak - - - - - - 12,000 - - - -
176 Lancet blood Buah - - - - - - - 623 - - - -
177 Lidokain Com, Inj Kombinasi Ampul - 30 30 30 - - - 1,433 42,990 42,990 - 687,840
178 Levofloksasin 500 mg Tablet - - - - - - - 520 - - - -
179 Loratadine Tablet 10 mg Tablet - - - - - - 1,400 185 - - - -
180 Loperamide 10 mg Tablet - - - - - - 1,400 - - - -
181 Maxiflow Baby (Masker Oksigen) Pcs - - - - - - 1,000 - - - -
182 Maxiflow Anak (Masker Oksigen) Pcs - - - - - - - - - - -
183 Maxiflow Dewasa (Masker Oksigen) Pcs - - - - - - - - - - -
184 Masker Botol - 20 20 5 - 15 20 1,226 24,520 6,130 - 207,194
185 Masker Respirator N-95 Buah - - - - - - 100 - - - -
186 Methilprednisolon Tablet 4 mg Tablet - - - - - - 2,000 - - - -
187 Methilergometrin Maleat Inj 0,200 mg/ml-1ml Tablet - - - - - - - 9,900 - - - -
188 Methilergometrin Maleat Tab salut 0,125 mg Tablet - - - - - - - 185 - - - -
189 Meloxicam 7,5 mg Tablet - - - - - - - - - - -
190 Meloxicam 15 mg Tablet - - - - - - - 1,719 - - - -
191 Metformin HCL Tab 500 mg Tablet - - - 90 - (90) - 138 - 12,420 - 1,690,500
192 Metformin HCL Tab 850 mg Tablet - 500 500 - - 500 - 168 84,000 - - 84,000
193 Metoklopramide Tab 10 mg Tablet - - - 167 - (167) - 117 - 19,539 - 2,917,278
194 Metronidasol Infus 500 mg/100 ml Botol - 48 48 12 - 36 20 11,547 554,256 138,564 - 1,524,204
195 Metronidasol Tab 250 mg Tablet - - - - - - - 99 - - - -
196 Metronidasol Tab 500 mg Tablet - - - - - - - 176 - - - -
197 Mikonazol Krim / Salf 2% ( Nitrat ) Tube - 24 24 16 - 8 - 4,268 102,432 68,288 - 627,396
198 Microlax Suppos Suppos - - - - - - - - - - -
199 Mucus Extractor Buah - - - - - - - - - - -
200 Natrium Diklofenak Tab 25 mg Tablet - - - 826 - (826) - 163 - 134,638 - 5,344,444
201 Natrium Diklofenak Tab 50 mg Tablet - - - 190 - (190) - 162 - 30,780 - 7,128,000
202 Natrium Klorida Larutan Infus 0,9% Steril Botol - 80 80 7 - 73 40 6,410 512,800 44,870 - 2,660,150
203 Nifedipin Tab 10 mg Tablet - - - 230 - (230) - 219 - 50,370 - 348,210
204 Nistatin 100.000 IU/g Tab Vaginal Tablet - 100 100 - - 100 100 858 85,800 - - 85,800
205 Nistatin 500.000 IU/ Tab Salut Tablet - - - - - - - 768 - - - -
206 NGT No. 6 Buah - - - - - - - 22,000 - - - -
207 NGT.No. 8 Buah - - - - - - - 22,000 - - - -
208 NGT.No.12 Buah - - - - - - - 22,000 - - - -
209 NGT.No.14 Buah - - - - - - - 22,000 - - - -
210 NGT.No.18 Buah - - - - - - - 22,000 - - - -
211 Obat Batuk Hitam Botol - 30 30 25 - 5 250 2,670 80,100 66,750 - 1,065,330
212 Omeprasol Tab 20 mg Tablet - 900 900 295 40 565 800 150 135,000 44,250 6,000 642,450
213 Ondansetron Tablet 4 mg Tablet - - - - - - - 1,090 - - - -
214 Obgyn Steril Handscoen Pcs - 100 100 - - 100 100 1,500 150,000 - - 150,000
215 Oralit/ Garam Oralit Saschet - - - 63 1,700 (1,763) 1,000 296 - 18,648 503,200 4,686,272
216 Objec Glass/Slide Pcs - - - - - - 100 - - - -
217 Oxibiotic injeksi Vial - - - - - - 50 - - - -
218 Oxitetrasikllin HCL Inj I.M 50mg/ml-10ml Vial - - - - - - - - - - -
219 Oxitetrasikllin HCL Salep Kulit 3% Tube - - - 1 2 (3) - 1,259 - 1,259 2,518 27,698
220 Oxitetrasikllin Salep Mata 1% Tube - - - - - - - 2,600 - - - -

LPLPO/KAB MBD Page 4


1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
221 Oxitosin Inj 10 IU /ml-1ml (pitogin Injeksi) Ampul - - - - - - - 3,020 - - - -
222 Oxyflow Baby Pcs - - - - - - 100 - - - -
223 Oxyflow Anak Pcs - - - - - - - - - - -
224 Oxyflow Dewasa Pcs - - - - - - - - - - -
225 Pap Smer Kit S Pcs - - - - - - - - - - -
226 Pap Smer Kit M Pcs - - - - - - - - - - -
227 Pap Smer Kit L Pcs - - - - - - - - - - -
228 Papaverin Inj 40mg/ml Ampul - - - - - - - - - - -
229 Papaverin Tab 40 mg Tablet - - - - - - - - - - -
230 Parasetamol Sirup 120 mg/ml Botol - - - 280 - (280) 200 1,252 - 350,560 - 2,679,280
231 Parasetamol Tab 500 mg Tablet - 3,300 3,300 7,731 - (4,431) 6,000 66 217,800 510,246 - 3,637,656
232 Pirantel Pamoat ( Pirantel ) Tab 125 mg Tablet - 200 200 56 325 (181) - 334 66,800 18,704 108,550 419,504
233 Piridoksin HCL ( Vit B6 ) Tab 10 mg Tablet - 500 500 - - 500 500 154 77,000 - - 77,000
234 Piroxicam Tab 10 mg Tablet - - - 960 - (960) - 334 - 320,640 - 14,789,520
235 Piroxicam Tab 20 mg Tablet - - - 490 - (490) - 244 - 119,560 - 708,820
236 Plester 5 Yard x 2 Inch Buah - 24 24 - - 24 10 - - - -
237 Pirasetam Tab 400 mg Tablet - - - - - - - - - - -
238 Pirasinamida Tab 500 mg Tablet - - - - - - - - - - -
239 Prednison Tab 5 mg Tablet - 5,500 5,500 6,401 - (901) 1,000 91 500,500 582,491 - 1,985,074
240 Primakuin Tab 15 mg Tablet - - - - - - - 175 - - - 1,050,000
241 Primperan Injeksi Vial - - - - - - - - - - -
242 Prokain Penisillin G Inj 3 Juta IU Ampul - - - - - - - 22,880 - - - -
243 Propanolol HCL ( Propanolol ) Tab 40 mg Tablet - - - - - - - 64 - - - -
244 Ranitidin Inj 25 mg/ml Vial - - - - - - 50 1,540 - - - -
245 Ranitidin Tab 150 mg Tablet - - - 1,340 - (1,340) - 121 - 162,140 - 6,538,840
246 Retinol ( Vit A ) Kapsul Lunak 100.000 IU Kapsul - 1,000 1,000 - 1,000 - 700 355 355,000 - 355,000 461,500
247 Retinol ( Vit A ) Kapsul Lunak 200.000 IU Kapsul - 1,100 1,100 58 - 1,042 - 648 712,800 37,584 - 4,625,424
248 Retinol ( Vit A ) Kapsul Lunak 50.000 IU Kapsul - - - - - - - - - - -
249 Ringer Laktat Larutan Infus Steril Botol - 140 140 52 - 88 72 7,150 1,001,000 371,800 - 3,038,750
250 Rivanol Larutan (Etakridin ) 300 ml Botol - - - 5 - (5) - 7,200 - 36,000 - 43,200
251 Salbutamol Tab 2 mg Tablet - - - - - - 1,000 - - - -
252 Salbutamol Tab 4 mg - 100 100 246 - (146) 500 81 8,100 19,926 - 410,346
253 Sefadroxil syrup 125mg/ml Botol - - - - - - 400 4,581 - - - -
254 Sefadroxil Kapsul 250 mg Kapsul - - - - - - 2,000 - - - -
255 Sefadroxil Kapsul 500 mg Kapsul - - - 329 - (329) 1,000 587 - 193,123 - 48,721
256 Setirizine Tab 10 mg Tablet - - - 30 - (30) 500 103 - 3,090 - 48,410
257 Setirizine Suspensi Botol - - - - - - 150 3,192 - - - -
258 Semen Seng Fosfat Serbuk dan Cairan Botol - - - - - - - - - - -
259 Sianokobalamin (Vit B12 ) Inj 500 mcg / ml-1ml vial - 100 100 - - 100 100 1,335 133,500 - - 1,068,000
260 Sianokobalamin ( Vit B12 ) Tab 50 mg Tablet - 5,000 5,000 1,712 - 3,288 - 53 265,000 90,736 - 3,665,904
261 Seftriakson Inj 1 g/Vial vial - - - - - - 100 5,143 - - - -
262 Sefotaxim Inj 1 g/ Vial vial - - - - - - 100 7,700 - - - -
263 Simetidin Tab 200 mg Tablet - - - - - - - - - - -
264 Simvastatin 5 mg Tablet - - - - - - 500 - - - -
265 Simvastatin Tab 10 mg Tablet - - - 124 - (124) 500 110 - 13,640 - 135,520
266 Siprofloxasin Tab 250 mg Tablet - - - - - - - - - - -
267 Siprofloxasin Tab 500 mg Tablet - - - 500 - (500) - 305 - 152,500 - 2,305,800
268 Scabimite Krim Tube - 10 10 1 - 9 100 37,525 375,250 37,525 - 337,725
269 Sofratule (Daryantull) Pcs - - - - - - - - - - -
270 Sohobion Injeksi Ampul - - - 30 - (30) 100 4,740 - 142,200 - 189,600
271 Silk Benang Bedah Sutera + Jarum No.2/0 75 cm Pcs - 36 36 - - 36 10 4,583 164,988 - - 164,988
272 Silk Benang Bedah Sutera + Jarum No.3/0 75 cm pcs - 36 36 - - 36 10 4,583 164,988 - - 164,988
273 Sofband Gips 6 Inch roll - - - - - - 2 37,500 - - - -
274 Sofband Gips 4 inch Roll - - - - - - 2 28,500 - - - -
275 Stik Glukosa Easy Touch Buah - - - - - - 150 - - - -
276 Stik As. Urat Easy Touch Buah - - - - - - 150 - - - -
277 Stik Kolesterol Easy Touch Buah - - - - - - 150 - - - -
278 Tetrasiklin Kapsul 250 mg Kapsul - - - - - - - 193 - - - -
279 Tetrasiklin Kapsul 500 mg Kapsul - 2,000 2,000 20 - 1,980 - 348 696,000 6,960 - 5,286,120

LPLPO/KAB MBD Page 5


1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
280 Terramycin Injeksi Vial - 10 10 - - 10 - 15,300 153,000 - - 153,000
281 Thiamin HCL / Monoitrat (Vit B1) Tab 50 mg Tablet - - - 2,593 - (2,593) 2,000 98 - 254,114 - 1,895,712
282 Thiamin HCL ( Vit B1 ) Inj 100 mg/ml-1ml Vial - - - - - - 50 - - - -
283 Tranfusi Set (Blood Set) Pcs - - - - - - - 3,600 - - - -
284 Tramadol injeksi Ampul - - - - - - - - - - -
285 Urine Bag pcs - 20 20 13 - 7 10 3,000 60,000 39,000 - 267,000
286 Ultra Sonic Gell Botol - - - - - - - 12,854 - - - -
287 Under Pad 60 cm x 90 Steril With SAP Pcs - - - - - - - - - - -
288 Ventolin injeksi (inhaler) Vial - - - - - - 100 - - - -
289 Ventolin Nebulizer Ampul - - - - - - 60 28,220 - - - -
290 Vaksin Verorab (Anti Rabies) vial - - - - - - 10 267,000 - - - -
291 Vitamin B Complex Tab Tablet - - - 1,442 - (1,442) 3,500 147 - 211,974 - 116,130
292 Vitamin B Complex Inj Ampul - - - - - - 200 11,273 - - - 1,127,300
293 Wing Needlee No. 23 pcs - - - - - - 200 14,000 - - - -
294 Wing Needlee No. 25 Pcs - - - - - - 200 14,000 - - - -
295 Wing Needlee No. 27 Pcs - - - - - - 200 14,000 - - - -
296 Yodium Povidon Larutan 10% - 60 ml Botol - - - 5 5 (10) 20 7,532 - 37,660 37,660 391,664
297 Yodium Povidon Larutan 10% - 300 ml Botol - - - - - - - - - - -
298 Yodium Povidon Larutan 10% - 1000 ml Botol - - - 4 - (4) 10 79,650 - 318,600 - 4,938,300
299 Zinc Tablet dispersible 20 mg Tablet - - - 190 - (190) 1,000 658 - 125,020 - 31,454,374
TOTAL HARGA 20,178,862 14,642,136 3,665,110 394,113,119

UMUM
JUMLAH KUNJUNGAN RESEP ASKES JUMLAH
BAYAR TIDAK BAYAR
0 0 …………………………………………. 2019

Mengetahui/Menyetujui; Yang Menyerahkan; Yang Meminta; Yang Menerima;


Kepala Dinas Kesehatan Kabupaten Petugas Gudang Farmasi, Pimpinan Puskesmas, Petugas Puskesmas,
Maluku Barat Daya,

NIP. NIP. NIP. NIP.

LPLPO/KAB MBD Page 6


Kode Puskesmas :
Puskesmas :
Kecamatan : Triwulan IV
Puskesmas Pembantu yg Ada ……………. TAHUN : 2019
Kabupaten : MALUKU BARAT DAYA
Provinsi : MALUKU
LAPORAN PEMAKAIAN DAN LEMBAR PERMINTAAN OBAT (LPLPO)

Total Harga Total Harga Total Harga


KODE/N STOK Kadaluwarsa/R STOK Harga Kadaluwarsa/R
NAMA OBAT dan PERBEKALAN KESEHATAN SATUAN PENERIMAAN PERSEDIAAN PEMAKAIAN SISA STOK PERMINTAAN Penerimaan Pemakaian Sisa Stock KET
O. URT AWAL usak APT Satuan (Rp) usak (Rp)
(Rp) (Rp) (Rp)

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
1 Alat Suntik Sekali Pakai 1 CC Buah - 100 100 - - 100 - 1,100 110,000 - - 110,000
2 Alat Suntik Sekali Pakai 2,5 CC Buah - 100 100 - - 100 - 1,750 175,000 - - 175,000
3 Alat Suntik Sekali Pakai 3 CC Buah (100) 100 - - - - 500 779 77,900 - - 77,900
4 Alat Suntik Sekali Pakai 5 CC Buah (500) - (500) 25 - (525) - 968 - 24,200 - 2,274,800
5 Alat Suntik Sekali Pakai 10 CC Buah - - - 15 185 (200) - 1,375 - 20,625 254,375 508,750
6 Alat Suntik Sekali Pakai 20 CC Buah - - - - - - - 1,500 - - - -
7 Abocath ( I.V. Catheter) No. 18 Buah - 50 50 - - 50 50 3,800 190,000 - - 190,000
8 Abocath (I.V.Catheter) No.20 Buah - 50 50 - - 50 50 3,800 190,000 - - 190,000
9 Abocath (I.V.Catheter) No.22 Buah - 50 50 3 - 47 50 3,800 190,000 11,400 - 178,600
10 Abocath (I.V.Catheter) No.24 Buah - 50 50 3 - 47 50 3,800 190,000 11,400 - 178,600
11 Abocath (I.V.Catheter) No.26 Buah - - - - - - 50 4,100 - - - -
12 Albendasol Tab 400 mg Tablet - - - - - - - 492 - - - -
13 Alkohol 70 % 1000 ml ( Etanol ) Botol 22 - 22 5 - 17 - 25,000 - 125,000 - 2,275,000
14 Alkohol 70 % 100 ml ( Etanol ) Botol - - - - - - 50 - - - -
15 Allopurinol Tab 100 mg Tablet (300) - (300) 320 - (620) - - - - -
16 Allopurinol Tab 300 mg Tablet - - - - - - - 108 - - - -
17 Ambroxol sirup 15 mg/ml Botol (14) - (14) 1 - (15) 200 6,095 - 6,095 - -
18 Ambroxol Tab 30 mg Tablet (1,564) 200 (1,364) 574 - (1,938) 1,500 201 40,200 115,374 - 1,072,536
19 Aminofillin inj 24 mg/ml-10 ml Ampul - - - - - - 50 3,280 - - - -
20 Aminofilin Tab 200 mg Tablet - - - - - - - 107 - - - 160,500
21 Amoxicillin Kaplet 250 mg Kaplet 4,580 - 4,580 2,420 - 2,160 3,000 212 - 513,040 - 2,014,000
22 Amoxicillin Kapsul 500 mg Kapsul 1,167 1,000 2,167 254 - 1,913 - 245 245,000 62,230 - 245,000
23 Amoxicillin Sirup Kering 125 mg/ 5 ml Botol (68) - (68) 11 - (79) 100 2,790 - 30,690 - -
24 Ampisillin Kaplet 250 mg Kaplet - - - - - - - - - - -
25 Ampisillin Kaplet 500 mg Kaplet (1,076) - (1,076) 570 - (1,646) 1,000 450 - 256,500 - 1,093,500
26 Ampisillin Serbuk Inj 1.m/ i.v 1000 mg/ml Vial - - - - - - 100 10,296 - - - -
27 Ampisillin sirup Kering 125 mg/ 5 ml Botol - - - - - - - - - - -
28 Amlodipin 5 mg tablet tablet (215) 500 285 140 - 145 500 99 49,500 13,860 - 841,005
29 Amlodipin 10 mg Tablet - - - - - - - 83 - - - -
30 Anvomer B6 Tab Tablet - - - - - - - 3,987 - - - -
31 Antasida Doen Tab Kombinasi Tablet (2,531) 300 (2,231) 962 - (3,193) - 58 17,400 55,796 - 680,108
32 Antasida Doen II Suspensi Botol (19) - (19) - - (19) 200 2,257 - - - -

33 Anti Fungi Doen Kombinasi (Asam Bensoat 3%+As.Salisilat 6% (22) - (22) - - (22) - 5,620 - - - 3,186,540
(Whitefield) Tube
34 Anti Malaria Doen Kombinasi (DHP) Tablet - - - - - - - 2,070 - - - -
35 Aquadest Steril (Air Untuk Injeksi Ampul 25 ml) Ampul - - - - - - 1,000 2,798 - - - -
36 Artemeter injeksi 80 mg/ml Ampul - - - - - - - 26,600 - - - -
37 Artesunat Injeksi Ampul - - - - - - - 48,750 - - - -
38 Asam Salisilat 2% + Belerang Endap 4% ( salf 2-4 ) Tube (17) - (17) - - (17) - 3,274 - - - -
39 Asam Askorbat ( Vit C ) Tab 50 mg Tablet 2,706 - 2,706 960 - 1,746 - 131 - 125,760 - 559,370
40 Asam Folat Tab 1 mg Tablet - - - 290 - (290) - 88 - 25,520 - 467,280
41 Asam Mefenamat Kapsul 250 mg Kaplet - - - - - - - - - - -
42 Asam Mefenamat Kaplet 500 mg Kaplet (2,970) 1,500 (1,470) 1,998 - (3,468) 1,500 195 292,500 389,610 - 413,400
43 Asam Traneksamat injeksi 100 mg/ml Ampul - - - - - - 50 2,798 - - - -
44 Aspar - K Tab Tablet - - - - - - - 4,312 - - - -
45 Atropina Sulfat Inj 0,25 mg/ml-1ml Ampul - - - - - - 50 1,914 - - - -
46 ATS Injeksi 1500 IU Ampul - - - - - - - 43,183 - - - -

LPLPO/KAB MBD Page 7


1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
47 Asiklovir Krim 5 % Tube - - - - - - 250 4,383 - - - -
48 Asiklovir Tab 200 mg Tablet - - - - - - - 236 - - - -
49 Asiklovir Tab 400 mg Tablet (159) - (159) 60 - (219) 1,400 414 - 24,840 - 525,780
50 Bedak Salysil Serbuk 2 % Dus - - - - - - 70 1,142 - - - -
51 Benzatin Bensil Penisillin 1,2 Juta IU Vial - - - - - - 50 - - - -

52 Bessi II Sulfat Tab Kombinasi : Besi II sulfat 7H2O 200 mg, Asam Tablet 1,970 - 1,970 500 - 1,470 2,000 445 - 222,500 - 2,318,450
Folat 0,25 mg (Fe = Tambah Darah)
53 Betametason 0,1% Krim Tube (7) - (7) 14 - (21) 100 1,520 - 21,280 - 136,800
54 Bisoprolol tab Tablet - - - - - - 1,000 - - - -
55 Bioplasenton gel Tube (2) - (2) - - (2) 150 17,928 - - - -
56 Buscopan Injeksi Ampul - - - - - - 50 - - - -
57 Bufacetin Salep Kulit Krim Tube - - - - - - - 4,024 - - - -
58 Captopril Tablet 12,5 mg Tablet (390) - (390) 320 - (710) - 87 - 27,840 - 455,097
59 Captopril Tablet 25 mg Tablet - - - - - - - 86 - - - -
60 Catgut Chromic + Jarum No. 2/0 75 cm Pcs - 24 24 - - 24 10 5,583 133,992 - - 133,992
61 Catgut Chromic + Jarum No. 3/0 75 cm Pcs - 24 24 - - 24 10 5,583 133,992 - - 133,992
62 Catgut Plain + Jarum No.2/0 75 cm Pcs - 24 24 - - 24 10 5,583 133,992 - - 133,992
63 Catgut Plain + Jarum No. 3/0 75 cm Pcs - 24 24 - - 24 10 5,583 133,992 - - 133,992
64 Catapres Injeksi Ampul - - - - - - 10 97,220 - - - -
65 Chloramfeniramine Maleat (Ctm) Tablet (3,075) 2,000 (1,075) 2,359 - (3,434) 4,000 26 52,000 61,334 - 45,292
66 Chloramfenikol Kapsul 250 mg Kapsul (80) - (80) 906 - (986) - 357 - 323,442 - 4,123,350
67 Chloramfenikol Kapsul 500 mg Kapsul - - - - - - - - - - -
68 Chloramfenikol Salf Mata 1% Tube (34) - (34) - - (34) 130 2,160 - - - -
69 Chloramfenikol Suspensi 125 mg/5 ml Botol - - - 20 - (20) - - - - -
70 Chloramfenikol Tetes Telinga 3 % Botol - - - - - - 60 2,590 - - - -
71 Chloramfenikol Salep Kulit 2 % Tube - - - - - - 50 4,042 - - - -
72 Clindamiciyn 150 mg Kapsul - - - - - - - 720 - - - 1,080,000
73 Clindamicin 300 mg Kapsul - - - - - - - 893 - - - -
74 Cotrimoxasol Suspensi Botol (114) - (114) - - (114) - 2,155 - - - -

75 Cotrimoxasol Tab kombinasi : Sulfametoksazole 400mg , Tablet (476) - (476) - - (476) 1,000 132 - - - -
Trimetroprim 80 mg
76 Dexamethason Inj 5 mg/ml-1 ml Vial (100) 100 - - - - 100 1,378 137,800 - - 137,800
77 Dexamethason Tab 0,5 mg Tablet (1,417) 300 (1,117) 30 - (1,147) 2,000 37 11,100 1,110 - 9,990
78 Diazepam Inj 5mg/ml-2ml Ampul - - - - - - - 2,150 - - - 193,500
79 Diazepam Tab 2 mg Tablet - - - - - - - 86 - - - -
80 Diazepam Tab 5 mg Tablet (70) - (70) 4 - (74) - 115 - 460 - 77,970
81 Difenhidramin HCL Inj 10 mg/ml-1 ml Vial - 100 100 - - 100 50 1,373 137,300 - - 137,300
82 Digoxin Tab 0,25 mg Tablet - - - - - - 300 104 - - - -
83 Dimenhidrinat Tablet 50 mg Tablet (800) - (800) - - (800) 1,000 - - - -
84 Doksisiklik Kapsul 100 mg Kapsul - - - - - - - 264 - - - -
85 Domperidon Tab 10 mg Tablet (116) - (116) 21 - (137) - 190 - 3,990 - 459,610
86 Dulcolax Tab Tablet - - - - - - 1,100 166 - - - -
87 Dulcolax Suppos Suppos - - - - - - 100 36,200 - - - -
88 Diltiasem HCL Tab 30 mg Tablet - - - - - - - 153 - - - -
89 Efedrin HCL ( Efedrina ) Tab 25 mg Tablet - - - - - - 200 - - - -
90 Elastic Verband 4 Inchi Buah - - - - - - 20 30,250 - - - 907,500
91 Elastic Verband 6 Inchi Buah - - - - - - 10 - - - -
92 Erlamycetin Tetes Telinga Botol - - - - - - 70 5,658 - - - -
93 Epinefrin HCL / Bitartrat ( Adrenalin ) Inj. 0,1%-1ml Ampul - - - - - - 150 2,486 - - - -
94 ErLamycetin Tetes Mata Botol (1) - (1) 1 - (2) 60 8,183 - 8,183 - 16,366
95 Eritr0misin Kapsul 250 mg Kapsul - - - - - - - 693 - - - -
96 Eritromisin Kapsul 500 mg Kapsul (37) - (37) - - (37) - 704 - - - 359,040
97 Eritromisin Sirup 200 mg/5 ml Botol (20) - (20) 10 - (30) - 6,788 - 67,880 - 1,588,392
98 Etil Klorida Spray Botol - - - - - - - - - - -
99 Etambutol HCL ( Etambutol ) Tab 250 mg Tablet - - - - - - 100 - - - -
100 Extension Tube Pcs - - - - - - - - - - -
101 Eugenol cairan Botol - - - - - - 20 20,000 - - - -
102 Fenobarbital Inj 50 mg/ml-2ml vial - - - - - - 20 2,325 - - - -
103 Fenobarbital Tab 30 mg Tablet (2,400) - (2,400) - - (2,400) - 243 - - - -

LPLPO/KAB MBD Page 8


1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
104 Fenol Gliseron tetes telinga 10 % Botol 9 24 33 4 - 29 10 2,590 62,160 10,360 - 82,880
105 Fitomenadion ( Vit K1 ) Inj 10 mg/ml-1ml Vial (90) - (90) - - (90) 50 4,438 - - - -
106 Fitomenadion ( Vit K1 ) Tab Salut 10 mg Tablet - - - - - - - 890 - - - 13,630,350
107 Foley Catheter T. 6 Botol - - - - - - 10 30,000 - - - -
108 Foley Catheter T. 8 Buah - 10 10 - - 10 10 30,000 300,000 - - 300,000
109 Foley Catheter T.10 Buah - 10 10 - - 10 10 30,000 300,000 - - 300,000
110 Foley Catheter T.12 Buah - 10 10 - - 10 10 8,000 80,000 - - 80,000
111 Foley Catheter T.14 Buah - 10 10 - - 10 10 8,000 80,000 - - 80,000
112 Foley Catheter T. 16 Buah - 10 10 - - 10 10 8,000 80,000 - - 80,000
113 Foley Catheter T.18 Buah - 10 10 - - 10 10 8,000 80,000 - - 80,000
114 Foley Catheter T. 20 Buah - 10 10 - - 10 10 8,000 80,000 - - 80,000
115 Foley Catheter T. 22 Buah - 10 10 - - 10 10 8,000 80,000 - - 80,000
116 Foley Catheter T. 24 Buah - 10 10 - - 10 10 8,000 80,000 - - 80,000
117 Flagystatin Tablet Vagina Tablet - - - - - - 30 29,520 - - - -
118 Furosemida Inj i.v i.m 10 mg/ml Vial - - - - - - 50 1,850 - - - -
119 Furosemida Tab 40 mg Tablet (40) - (40) 47 - (87) - 88 - 4,136 - 71,280
120 Formalin Cairan Botol - - - - - - 15 - - - -
121 Gentamisin Inj 80 mg/ 2ml Ampul - - - - - - 30 3,854 - - - -
122 Gentamisin Salf Kulit 0,1 % Tube (20) - (20) - - (20) - - - - -
123 Gentamisin Slufat Tetes Mata 0,3 % Botol - - - - - - 60 5,020 - - - -
124 Glimepride Tab 4 mg Tablet - - - - - - 1,000 273 - - - -
125 Gentian Violet Larutan 1 % Botol (1) - (1) 3 - (4) - 5,200 - 15,600 - 228,800
126 Gipsonal Gipsum 4 Inchi Buah - - - - - - 10 28,500 - - - -
127 Gipsonal Gipsum 6 Inchi Buah - - - - - - 10 37,500 - - - -
128 Glibenclamide Tab Tablet (10) - (10) - - (10) - 720 - - - 1,587,600
129 Gliseril Guaiakolat Tab 100 mg/ Guafenisine Tablet (3,889) 100 (3,789) 2,326 - (6,115) 1,000 132 13,200 307,032 - 1,187,340
130 Glukosa Larutan Infus 5 % Steril Botol 40 - 40 - 20 20 72 6,900 - - 138,000 276,000
131 Glukosa Larutan Infus 10 % Steril Botol - - - - - - - 6,840 - - - -
132 Glukosa Larutan Infus 40 % Steril Botol - - - - - - - - - - -
133 Griseovulvin Tab 125 mg, Micronized Tablet 1,930 - 1,930 36 - 1,894 - 242 - 8,712 - 1,530,408
134 Handscoen S Pcs - - - - - - - - - - -
135 Handscoen M Pcs - 200 200 - - 200 200 - - - -
136 Handscoen L Pcs - 200 200 - - 200 300 - - - -
137 Handscoen No. 6 Pcs - - - - - - - - - - -
138 Handscoen No.7 Pcs - 100 100 - - 100 100 6,985 698,500 - - 698,500
139 Handscoen No.7,5 Pcs - 100 100 - - 100 100 6,985 698,500 - - 698,500
140 Hidroklorotiasida ( HCT ) Tab 25 mg Tablet - - - - - - - 194 - - - -
141 Hidrokortison Krim 2,5 mg Tube (5) - (5) 22 - (27) - 2,846 - 62,612 - 791,188
142 Ibuprofen Suspensi Botol - 100 100 8 - 92 100 5,739 573,900 45,912 - 527,988
143 Ibuprofen Tab 200 mg Tablet - - - - - - - - - - -
144 Ibuprofen Tab 400 mg Tablet - - - - - - 1,000 - - - -
145 Infusion Set Anak Pcs 150 - 150 - 150 - 150 3,500 - - 525,000 1,050,000
146 Infusion Set Dewasa Pcs (70) - (70) 20 - (90) - 3,200 - 64,000 - 384,000
147 Isoniasid ( INH ) Tab 100 mg Tablet - - - - - - - - - - -
148 Isoniasid ( INH ) Tab 300 mg Tablet - - - - - - - 165 - - - -
149 Isosorbid Dinitrat Tab Sublingual 5 mg Tablet - - - - - - 100 - - - -
150 Kalium Glukonat injeksi 10% (100mg/ml) Ampul - - - - - - 50 7,800 - - - -
151 Kalsium Laktat ( Kalk ) Tab 500 mg Tablet 1,900 - 1,900 285 - 1,615 - 62 - 17,670 - 276,520
152 Karbamasepin Tab 200 mg Tablet - - - - - - - 241 - - - -
KAEN-3B Larutan infus (mengandung NaCl 1,75+KCL 1,5gr+ Na
153 Lactat 2,24 gr, Dextrose 27 gr) Botol - - - - - - 108 23,500 - - - -

154 Kapas Putih 1000 gr (Kapas Putih 1 Kg) Roll - 2 2 1 - 1 6 - - - -


155 Kantung Darah 250 cc Roll - - - - - - - - - - -
156 Kapas Pembalut Absorben 250 Gram Roll - - - - - - 10 22,000 - - - -
157 Kapas Berlemak 500 mg Buah (2) - (2) 2 - (4) - 16,500 - 33,000 - 280,500
158 Kasa Roll Panjang Besar 40x80 Cm Buah (1) 4 3 1 - 2 4 105,000 420,000 105,000 - 945,000
159 Kasa Kompres 40/40 Steril Buah 50 200 250 75 - 175 - 1,600 320,000 120,000 - 1,640,000
160 Kasa Pembalut Hidrofil Steril 16 cm x 16 cm Buah - 10 10 - - 10 - 8,000 80,000 - - 80,000
161 Kasa Pembalut Hidrofil Supergrade 40 cm x 16 cm Buah (6) - (6) - - (6) - 36,960 - - - -

LPLPO/KAB MBD Page 9


1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
162 Kasa Steril 10 cm x 10 cm Buah - - - - - - - - - - -
163 Keterolac Inj 30 mg Ampul - - - - - - 100 1,265 - - - -
164 Ketokonazole Tab 200 mg Tablet (180) - (180) 40 - (220) - 311 - 12,440 - 1,054,290
165 Ketokonazole Krim Tube (39) - (39) 5 - (44) - 2,893 - 14,465 - 419,485
166 Kinina Dihidroklorida ( Kina ) Inj 25 %-2ml Ampul - - - - - - - 7,440 - - - -
167 Kuinin Sulfat Tab 222 mg ( H2O ) (Qunine 222 mg) Tablet - - - - - - - 799 - - - 719,100
168 Klorpromasin HCL Tab Salut 25 mg Tablet - - - - - - - - - - -
169 Klorpromasin HCL Tab Salut 100 mg Tablet - - - - - - - 179 - - - 107,400
170 Klorpromasin Inj 25 mg/ml-1ml Ampul - - - - - - - 1,550 - - - -
171 Klorpromasin Inj 5 mg/ ml-2ml Ampul - - - - - - - - - - -
172 Kodein HCL ( Kodeina ) Tab 10 mg Tablet - - - - - - - 600 - - - -
173 Klip Plastik 7 x 10 cm Pak - - - - - - 7,000 - - - -
174 Klip Plastik 8 x 5 cm Pak - - - - - - 7,000 - - - -
175 Kertas pulvis Pak - - - - - - 12,000 - - - -
176 Lancet blood Buah - - - - - - - 623 - - - -
177 Lidokain Com, Inj Kombinasi Ampul - - - - - - - 1,433 - - - 128,970
178 Levofloksasin 500 mg Tablet - - - - - - - 520 - - - -
179 Loratadine Tablet 10 mg Tablet - - - - - - 1,400 185 - - - -
180 Loperamide 10 mg Tablet - - - - - - 1,400 - - - -
181 Maxiflow Baby (Masker Oksigen) Pcs - - - - - - 1,000 - - - -
182 Maxiflow Anak (Masker Oksigen) Pcs - - - - - - - - - - -
183 Maxiflow Dewasa (Masker Oksigen) Pcs - - - - - - - - - - -
184 Masker Botol 20 - 20 5 - 15 20 1,226 - 6,130 - 60,074
185 Masker Respirator N-95 Buah - - - - - - 100 - - - -
186 Methilprednisolon Tablet 4 mg Tablet - - - - - - 2,000 - - - -
187 Methilergometrin Maleat Inj 0,200 mg/ml-1ml Tablet - - - - - - - 9,900 - - - -
188 Methilergometrin Maleat Tab salut 0,125 mg Tablet - - - - - - - 185 - - - -
189 Meloxicam 7,5 mg Tablet - - - - - - - - - - -
190 Meloxicam 15 mg Tablet - - - - - - - 1,719 - - - -
191 Metformin HCL Tab 500 mg Tablet (10) - (10) 80 - (90) - 138 - 11,040 - 481,620
192 Metformin HCL Tab 850 mg Tablet - 500 500 - - 500 - 168 84,000 - - 84,000
193 Metoklopramide Tab 10 mg Tablet (167) - (167) - - (167) - 117 - - - 631,800
194 Metronidasol Infus 500 mg/100 ml Botol 12 24 36 - - 36 20 11,547 277,128 - - 692,820
195 Metronidasol Tab 250 mg Tablet - - - - - - - 99 - - - -
196 Metronidasol Tab 500 mg Tablet - - - - - - - 176 - - - -
197 Mikonazol Krim / Salf 2% ( Nitrat ) Tube (16) 24 8 - - 8 - 4,268 102,432 - - 102,432
198 Microlax Suppos Suppos - - - - - - - - - - -
199 Mucus Extractor Buah - - - - - - - - - - -
200 Natrium Diklofenak Tab 25 mg Tablet (616) - (616) 210 - (826) - 163 - 34,230 - 1,437,660
201 Natrium Diklofenak Tab 50 mg Tablet - - - 190 - (190) - 162 - 30,780 - 2,081,700
202 Natrium Klorida Larutan Infus 0,9% Steril Botol 73 - 73 - - 73 40 6,410 - - - -
203 Nifedipin Tab 10 mg Tablet (180) - (180) 50 - (230) - 219 - 10,950 - 52,560
204 Nistatin 100.000 IU/g Tab Vaginal Tablet - 100 100 - - 100 100 858 85,800 - - 85,800
205 Nistatin 500.000 IU/ Tab Salut Tablet - - - - - - - 768 - - - -
206 NGT No. 6 Buah - - - - - - - 22,000 - - - -
207 NGT.No. 8 Buah - - - - - - - 22,000 - - - -
208 NGT.No.12 Buah - - - - - - - 22,000 - - - -
209 NGT.No.14 Buah - - - - - - - 22,000 - - - -
210 NGT.No.18 Buah - - - - - - - 22,000 - - - -
211 Obat Batuk Hitam Botol 26 - 26 21 - 5 250 2,670 - 56,070 - 80,100
212 Omeprasol Tab 20 mg Tablet 716 - 716 111 40 565 800 150 - 16,650 6,000 63,750
213 Ondansetron Tablet 4 mg Tablet - - - - - - - 1,090 - - - -
214 Obgyn Steril Handscoen Pcs - 100 100 - - 100 100 1,500 150,000 - - 150,000
215 Oralit/ Garam Oralit Saschet (63) - (63) - 1,700 (1,763) 1,000 296 - - 503,200 1,006,400
216 Objec Glass/Slide Pcs - - - - - - 100 - - - -
217 Oxibiotic injeksi Vial - - - - - - 50 - - - -
218 Oxitetrasikllin HCL Inj I.M 50mg/ml-10ml Vial - - - - - - - - - - -
219 Oxitetrasikllin HCL Salep Kulit 3% Tube (1) - (1) - 2 (3) - 1,259 - - 2,518 5,036
220 Oxitetrasikllin Salep Mata 1% Tube - - - - - - - 2,600 - - - -

LPLPO/KAB MBD Page 10


1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
221 Oxitosin Inj 10 IU /ml-1ml (pitogin Injeksi) Ampul - - - - - - - 3,020 - - - -
222 Oxyflow Baby Pcs - - - - - - 100 - - - -
223 Oxyflow Anak Pcs - - - - - - - - - - -
224 Oxyflow Dewasa Pcs - - - - - - - - - - -
225 Pap Smer Kit S Pcs - - - - - - - - - - -
226 Pap Smer Kit M Pcs - - - - - - - - - - -
227 Pap Smer Kit L Pcs - - - - - - - - - - -
228 Papaverin Inj 40mg/ml Ampul - - - - - - - - - - -
229 Papaverin Tab 40 mg Tablet - - - - - - - - - - -
230 Parasetamol Sirup 120 mg/ml Botol (53) - (53) 227 - (280) 200 1,252 - 284,204 - 291,716
231 Parasetamol Tab 500 mg Tablet (2,463) 300 (2,163) 2,268 - (4,431) 6,000 66 19,800 149,688 - 284,856
232 Pirantel Pamoat ( Pirantel ) Tab 125 mg Tablet (161) - (161) 20 - (181) - 334 - 6,680 - 132,264
233 Piridoksin HCL ( Vit B6 ) Tab 10 mg Tablet - 500 500 - - 500 500 154 77,000 - - 77,000
234 Piroxicam Tab 10 mg Tablet (385) - (385) 575 - (960) - 334 - 192,050 - 3,652,290
235 Piroxicam Tab 20 mg Tablet (490) - (490) - - (490) - 244 - - - -
236 Plester 5 Yard x 2 Inch Buah - 24 24 - - 24 10 - - - -
237 Pirasetam Tab 400 mg Tablet - - - - - - - - - - -
238 Pirasinamida Tab 500 mg Tablet - - - - - - - - - - -
239 Prednison Tab 5 mg Tablet (1,381) 500 (881) 20 - (901) 1,000 91 45,500 1,820 - 43,680
240 Primakuin Tab 15 mg Tablet - - - - - - - 175 - - - 1,050,000
241 Primperan Injeksi Vial - - - - - - - - - - -
242 Prokain Penisillin G Inj 3 Juta IU Ampul - - - - - - - 22,880 - - - -
243 Propanolol HCL ( Propanolol ) Tab 40 mg Tablet - - - - - - - 64 - - - -
244 Ranitidin Inj 25 mg/ml Vial - - - - - - 50 1,540 - - - -
245 Ranitidin Tab 150 mg Tablet (800) - (800) 540 - (1,340) - 121 - 65,340 - 1,736,350
246 Retinol ( Vit A ) Kapsul Lunak 100.000 IU Kapsul - - - - - - 700 355 - - - 106,500
247 Retinol ( Vit A ) Kapsul Lunak 200.000 IU Kapsul 950 100 1,050 8 - 1,042 - 648 64,800 5,184 - 1,515,024
248 Retinol ( Vit A ) Kapsul Lunak 50.000 IU Kapsul - - - - - - - - - - -
249 Ringer Laktat Larutan Infus Steril Botol 52 60 112 24 - 88 72 7,150 429,000 171,600 - 371,800
250 Rivanol Larutan (Etakridin ) 300 ml Botol (5) - (5) - - (5) - 7,200 - - - -
251 Salbutamol Tab 2 mg Tablet - - - - - - 1,000 - - - -
252 Salbutamol Tab 4 mg (146) - (146) - - (146) 500 81 - - - -
253 Sefadroxil syrup 125mg/ml Botol - - - - - - 400 4,581 - - - -
254 Sefadroxil Kapsul 250 mg Kapsul - - - - - - 2,000 - - - -
255 Sefadroxil Kapsul 500 mg Kapsul (329) - (329) - - (329) 1,000 587 - - - -
256 Setirizine Tab 10 mg Tablet - - - 30 - (30) 500 103 - 3,090 - 48,410
257 Setirizine Suspensi Botol - - - - - - 150 3,192 - - - -
258 Semen Seng Fosfat Serbuk dan Cairan Botol - - - - - - - - - - -
259 Sianokobalamin (Vit B12 ) Inj 500 mcg / ml-1ml vial 100 - 100 - - 100 100 1,335 - - - 400,500
260 Sianokobalamin ( Vit B12 ) Tab 50 mg Tablet 3,832 - 3,832 544 - 3,288 - 53 - 28,832 - 968,946
261 Seftriakson Inj 1 g/Vial vial - - - - - - 100 5,143 - - - -
262 Sefotaxim Inj 1 g/ Vial vial - - - - - - 100 7,700 - - - -
263 Simetidin Tab 200 mg Tablet - - - - - - - - - - -
264 Simvastatin 5 mg Tablet - - - - - - 500 - - - -
265 Simvastatin Tab 10 mg Tablet (86) - (86) 38 - (124) 500 110 - 4,180 - -
266 Siprofloxasin Tab 250 mg Tablet - - - - - - - - - - -
267 Siprofloxasin Tab 500 mg Tablet (200) - (200) 300 - (500) - 305 - 91,500 - 430,050
268 Scabimite Krim Tube - 10 10 1 - 9 100 37,525 375,250 37,525 - 337,725
269 Sofratule (Daryantull) Pcs - - - - - - - - - - -
270 Sohobion Injeksi Ampul (30) - (30) - - (30) 100 4,740 - - - -
271 Silk Benang Bedah Sutera + Jarum No.2/0 75 cm Pcs - 36 36 - - 36 10 4,583 164,988 - - 164,988
272 Silk Benang Bedah Sutera + Jarum No.3/0 75 cm pcs - 36 36 - - 36 10 4,583 164,988 - - 164,988
273 Sofband Gips 6 Inch roll - - - - - - 2 37,500 - - - -
274 Sofband Gips 4 inch Roll - - - - - - 2 28,500 - - - -
275 Stik Glukosa Easy Touch Buah - - - - - - 150 - - - -
276 Stik As. Urat Easy Touch Buah - - - - - - 150 - - - -
277 Stik Kolesterol Easy Touch Buah - - - - - - 150 - - - -
278 Tetrasiklin Kapsul 250 mg Kapsul - - - - - - - 193 - - - -
279 Tetrasiklin Kapsul 500 mg Kapsul 1,980 - 1,980 - - 1,980 - 348 - - - 1,827,000

LPLPO/KAB MBD Page 11


1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
280 Terramycin Injeksi Vial - 10 10 - - 10 - 15,300 153,000 - - 153,000
281 Thiamin HCL / Monoitrat (Vit B1) Tab 50 mg Tablet (1,503) - (1,503) 1,090 - (2,593) 2,000 98 - 106,820 - 97,706
282 Thiamin HCL ( Vit B1 ) Inj 100 mg/ml-1ml Vial - - - - - - 50 - - - -
283 Tranfusi Set (Blood Set) Pcs - - - - - - - 3,600 - - - -
284 Tramadol injeksi Ampul - - - - - - - - - - -
285 Urine Bag pcs (8) 20 12 5 - 7 10 3,000 60,000 15,000 - 174,000
286 Ultra Sonic Gell Botol - - - - - - - 12,854 - - - -
287 Under Pad 60 cm x 90 Steril With SAP Pcs - - - - - - - - - - -
288 Ventolin injeksi (inhaler) Vial - - - - - - 100 - - - -
289 Ventolin Nebulizer Ampul - - - - - - 60 28,220 - - - -
290 Vaksin Verorab (Anti Rabies) vial - - - - - - 10 267,000 - - - -
291 Vitamin B Complex Tab Tablet (1,442) - (1,442) - - (1,442) 3,500 147 - - - -
292 Vitamin B Complex Inj Ampul - - - - - - 200 11,273 - - - 338,190
293 Wing Needlee No. 23 pcs - - - - - - 200 14,000 - - - -
294 Wing Needlee No. 25 Pcs - - - - - - 200 14,000 - - - -
295 Wing Needlee No. 27 Pcs - - - - - - 200 14,000 - - - -
296 Yodium Povidon Larutan 10% - 60 ml Botol (5) - (5) - 5 (10) 20 7,532 - - 37,660 75,320
297 Yodium Povidon Larutan 10% - 300 ml Botol - - - - - - - - - - -
298 Yodium Povidon Larutan 10% - 1000 ml Botol (2) - (2) 2 - (4) 10 79,650 - 159,300 - 876,150
299 Zinc Tablet dispersible 20 mg Tablet (90) - (90) 100 - (190) 1,000 658 - 65,800 - 9,152,780
TOTAL HARGA 8,921,614 4,925,361 1,466,753 91,043,178

UMUM
JUMLAH KUNJUNGAN RESEP ASKES JUMLAH
BAYAR TIDAK BAYAR
0 0 …………………………………………. 2019

Mengetahui/Menyetujui; Yang Menyerahkan; Yang Meminta; Yang Menerima;


Kepala Dinas Kesehatan Kabupaten Petugas Gudang Farmasi, Pimpinan Puskesmas, Petugas Puskesmas,
Maluku Barat Daya,

NIP. NIP. NIP. NIP.

LPLPO/KAB MBD Page 12


Kode Puskesmas :
Puskesmas :
Kecamatan : Triwulan III
Puskesmas Pembantu yg Ada ……………. TAHUN : 2019
Kabupaten : MALUKU BARAT DAYA
Provinsi : MALUKU
LAPORAN PEMAKAIAN DAN LEMBAR PERMINTAAN OBAT (LPLPO)

Total Harga Total Harga Total Harga


KODE/N STOK Kadaluwarsa/R STOK Harga Kadaluwarsa/R
NAMA OBAT dan PERBEKALAN KESEHATAN SATUAN PENERIMAAN PERSEDIAAN PEMAKAIAN SISA STOK PERMINTAAN Penerimaan Pemakaian Sisa Stock KET
O. URT AWAL usak APT Satuan (Rp) usak (Rp)
(Rp) (Rp) (Rp)

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
1 Alat Suntik Sekali Pakai 1 CC Buah - - - - - - - 1,100 - - - 3,630,000
2 Alat Suntik Sekali Pakai 2,5 CC Buah - - - - - - - 1,750 - - - -
3 Alat Suntik Sekali Pakai 3 CC Buah - - - 100 - (100) - 779 - 77,900 - -
4 Alat Suntik Sekali Pakai 5 CC Buah - - - - 500 (500) - 968 - - 484,000 1,161,600
5 Alat Suntik Sekali Pakai 10 CC Buah - - - - - - - 1,375 - - - 825,000
6 Alat Suntik Sekali Pakai 20 CC Buah - - - - - - - 1,500 - - - -
7 Abocath ( I.V. Catheter) No. 18 Buah - - - - - - - 3,800 - - - -
8 Abocath (I.V.Catheter) No.20 Buah - - - - - - - 3,800 - - - 2,280,000
9 Abocath (I.V.Catheter) No.22 Buah - - - - - - - 3,800 - - - 2,850,000
10 Abocath (I.V.Catheter) No.24 Buah - - - - - - - 3,800 - - - 2,280,000
11 Abocath (I.V.Catheter) No.26 Buah - - - - - - - 4,100 - - - -
12 Albendasol Tab 400 mg Tablet - - - - - - - 492 - - - -
13 Alkohol 70 % 1000 ml ( Etanol ) Botol 23 - 23 1 - 22 - 25,000 - 25,000 - 2,250,000
14 Alkohol 70 % 100 ml ( Etanol ) Botol - - - - - - - - - - -
15 Allopurinol Tab 100 mg Tablet (260) - (260) 40 - (300) - - - - -
16 Allopurinol Tab 300 mg Tablet - - - - - - - 108 - - - -
17 Ambroxol sirup 15 mg/ml Botol (11) - (11) 3 - (14) - 6,095 - 18,285 - 109,710
18 Ambroxol Tab 30 mg Tablet (1,422) - (1,422) 142 - (1,564) - 201 - 28,542 - 1,813,221
19 Aminofillin inj 24 mg/ml-10 ml Ampul - - - - - - - 3,280 - - - -
20 Aminofilin Tab 200 mg Tablet - - - - - - - 107 - - - -
21 Amoxicillin Kaplet 250 mg Kaplet 4,780 - 4,780 200 - 4,580 - 212 - 42,400 - 2,912,880
22 Amoxicillin Kapsul 500 mg Kapsul 1,812 - 1,812 645 - 1,167 - 245 - 158,025 - 857,745
23 Amoxicillin Sirup Kering 125 mg/ 5 ml Botol (33) - (33) 35 - (68) - 2,790 - 97,650 - 1,230,390
24 Ampisillin Kaplet 250 mg Kaplet - - - - - - - - - - -
25 Ampisillin Kaplet 500 mg Kaplet (876) - (876) 200 - (1,076) - 450 - 90,000 - 2,160,000
26 Ampisillin Serbuk Inj 1.m/ i.v 1000 mg/ml Vial - - - - - - - 10,296 - - - -
27 Ampisillin sirup Kering 125 mg/ 5 ml Botol - - - - - - - - - - -
28 Amlodipin 5 mg tablet tablet (195) - (195) 20 - (215) - 99 - 1,980 - 827,145
29 Amlodipin 10 mg Tablet - - - - - - - 83 - - - -
30 Anvomer B6 Tab Tablet - - - - - - - 3,987 - - - -
31 Antasida Doen Tab Kombinasi Tablet (1,835) - (1,835) 696 - (2,531) - 58 - 40,368 - 1,942,710
32 Antasida Doen II Suspensi Botol (19) - (19) - - (19) - 2,257 - - - -

33 Anti Fungi Doen Kombinasi (Asam Bensoat 3%+As.Salisilat 6% (21) - (21) 1 - (22) - 5,620 - 5,620 - 3,624,900
(Whitefield) Tube
34 Anti Malaria Doen Kombinasi (DHP) Tablet - - - - - - - 2,070 - - - -
35 Aquadest Steril (Air Untuk Injeksi Ampul 25 ml) Ampul - - - - - - - 2,798 - - - -
36 Artemeter injeksi 80 mg/ml Ampul - - - - - - - 26,600 - - - 2,394,000
37 Artesunat Injeksi Ampul - - - - - - - 48,750 - - - -
38 Asam Salisilat 2% + Belerang Endap 4% ( salf 2-4 ) Tube (12) - (12) 5 - (17) - 3,274 - 16,370 - 441,990
39 Asam Askorbat ( Vit C ) Tab 50 mg Tablet 2,858 - 2,858 152 - 2,706 - 131 - 19,912 - 1,063,458
40 Asam Folat Tab 1 mg Tablet - - - - - - - 88 - - - -
41 Asam Mefenamat Kapsul 250 mg Kaplet - - - - - - - - - - -
42 Asam Mefenamat Kaplet 500 mg Kaplet (2,600) - (2,600) 370 - (2,970) - 195 - 72,150 - 485,550
43 Asam Traneksamat injeksi 100 mg/ml Ampul - - - - - - - 2,798 - - - -
44 Aspar - K Tab Tablet - - - - - - - 4,312 - - - -
45 Atropina Sulfat Inj 0,25 mg/ml-1ml Ampul - - - - - - - 1,914 - - - -
46 ATS Injeksi 1500 IU Ampul - - - - - - - 43,183 - - - -

LPLPO/KAB MBD Page 13


1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
47 Asiklovir Krim 5 % Tube - - - - - - - 4,383 - - - -
48 Asiklovir Tab 200 mg Tablet - - - - - - - 236 - - - -
49 Asiklovir Tab 400 mg Tablet (90) - (90) 69 - (159) - 414 - 28,566 - 676,890
50 Bedak Salysil Serbuk 2 % Dus - - - - - - - 1,142 - - - -
51 Benzatin Bensil Penisillin 1,2 Juta IU Vial - - - - - - - - - - -

52 Bessi II Sulfat Tab Kombinasi : Besi II sulfat 7H2O 200 mg, Asam Tablet 2,000 - 2,000 30 - 1,970 - 445 - 13,350 - 2,629,950
Folat 0,25 mg (Fe = Tambah Darah)
53 Betametason 0,1% Krim Tube (2) - (2) 5 - (7) - 1,520 - 7,600 - 456,000
54 Bisoprolol tab Tablet - - - - - - - - - - -
55 Bioplasenton gel Tube (2) - (2) - - (2) - 17,928 - - - -
56 Buscopan Injeksi Ampul - - - - - - - - - - -
57 Bufacetin Salep Kulit Krim Tube - - - - - - - 4,024 - - - -
58 Captopril Tablet 12,5 mg Tablet (326) - (326) 64 - (390) - 87 - 5,568 - 673,380
59 Captopril Tablet 25 mg Tablet - - - - - - - 86 - - - -
60 Catgut Chromic + Jarum No. 2/0 75 cm Pcs - - - - - - - 5,583 - - - -
61 Catgut Chromic + Jarum No. 3/0 75 cm Pcs - - - - - - - 5,583 - - - -
62 Catgut Plain + Jarum No.2/0 75 cm Pcs - - - - - - - 5,583 - - - 803,952
63 Catgut Plain + Jarum No. 3/0 75 cm Pcs - - - - - - - 5,583 - - - -
64 Catapres Injeksi Ampul - - - - - - - 97,220 - - - -
65 Chloramfeniramine Maleat (Ctm) Tablet (2,419) - (2,419) 656 - (3,075) - 26 - 17,056 - 282,750
66 Chloramfenikol Kapsul 250 mg Kapsul (70) - (70) 10 - (80) - 357 - 3,570 - 5,104,386
67 Chloramfenikol Kapsul 500 mg Kapsul - - - - - - - - - - -
68 Chloramfenikol Salf Mata 1% Tube (33) - (33) 1 - (34) - 2,160 - 2,160 - 881,280
69 Chloramfenikol Suspensi 125 mg/5 ml Botol - - - - - - - - - - -
70 Chloramfenikol Tetes Telinga 3 % Botol - - - - - - - 2,590 - - - -
71 Chloramfenikol Salep Kulit 2 % Tube - - - - - - - 4,042 - - - -
72 Clindamiciyn 150 mg Kapsul - - - - - - - 720 - - - 1,080,000
73 Clindamicin 300 mg Kapsul - - - - - - - 893 - - - -
74 Cotrimoxasol Suspensi Botol (17) - (17) - 97 (114) - 2,155 - - 209,035 -

75 Cotrimoxasol Tab kombinasi : Sulfametoksazole 400mg , Tablet (446) - (446) 30 - (476) - 132 - 3,960 - 2,871,000
Trimetroprim 80 mg
76 Dexamethason Inj 5 mg/ml-1 ml Vial (100) - (100) - - (100) - 1,378 - - - 413,400
77 Dexamethason Tab 0,5 mg Tablet (1,417) - (1,417) - - (1,417) - 37 - - - 266,400
78 Diazepam Inj 5mg/ml-2ml Ampul - - - - - - - 2,150 - - - 193,500
79 Diazepam Tab 2 mg Tablet - - - - - - - 86 - - - -
80 Diazepam Tab 5 mg Tablet (70) - (70) - - (70) - 115 - - - 79,350
81 Difenhidramin HCL Inj 10 mg/ml-1 ml Vial - - - - - - - 1,373 - - - -
82 Digoxin Tab 0,25 mg Tablet - - - - - - - 104 - - - 156,000
83 Dimenhidrinat Tablet 50 mg Tablet (800) - (800) - - (800) - - - - -
84 Doksisiklik Kapsul 100 mg Kapsul - - - - - - - 264 - - - -
85 Domperidon Tab 10 mg Tablet (96) - (96) 20 - (116) - 190 - 3,800 - 481,080
86 Dulcolax Tab Tablet - - - - - - - 166 - - - -
87 Dulcolax Suppos Suppos - - - - - - - 36,200 - - - -
88 Diltiasem HCL Tab 30 mg Tablet - - - - - - - 153 - - - -
89 Efedrin HCL ( Efedrina ) Tab 25 mg Tablet - - - - - - - - - - -
90 Elastic Verband 4 Inchi Buah - - - - - - - 30,250 - - - 907,500
91 Elastic Verband 6 Inchi Buah - - - - - - - - - - -
92 Erlamycetin Tetes Telinga Botol - - - - - - - 5,658 - - - -
93 Epinefrin HCL / Bitartrat ( Adrenalin ) Inj. 0,1%-1ml Ampul - - - - - - - 2,486 - - - -
94 ErLamycetin Tetes Mata Botol (1) - (1) - - (1) - 8,183 - - - 24,549
95 Eritr0misin Kapsul 250 mg Kapsul - - - - - - - 693 - - - -
96 Eritromisin Kapsul 500 mg Kapsul (8) - (8) 29 - (37) - 704 - 20,416 - 555,456
97 Eritromisin Sirup 200 mg/5 ml Botol (20) - (20) - - (20) - 6,788 - - - 2,036,400
98 Etil Klorida Spray Botol - - - - - - - - - - -
99 Etambutol HCL ( Etambutol ) Tab 250 mg Tablet - - - - - - - - - - -
100 Extension Tube Pcs - - - - - - - - - - -
101 Eugenol cairan Botol - - - - - - - 20,000 - - - -
102 Fenobarbital Inj 50 mg/ml-2ml vial - - - - - - - 2,325 - - - -
103 Fenobarbital Tab 30 mg Tablet (2,400) - (2,400) - - (2,400) - 243 - - - -

LPLPO/KAB MBD Page 14


1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
104 Fenol Gliseron tetes telinga 10 % Botol 9 - 9 - - 9 - 2,590 - - - 69,930
105 Fitomenadion ( Vit K1 ) Inj 10 mg/ml-1ml Vial (90) - (90) - - (90) - 4,438 - - - -
106 Fitomenadion ( Vit K1 ) Tab Salut 10 mg Tablet - - - - - - - 890 - - - 15,219,000
107 Foley Catheter T. 6 Botol - - - - - - - 30,000 - - - -
108 Foley Catheter T. 8 Buah - - - - - - - 30,000 - - - -
109 Foley Catheter T.10 Buah - - - - - - - 30,000 - - - -
110 Foley Catheter T.12 Buah - - - - - - - 8,000 - - - -
111 Foley Catheter T.14 Buah - - - - - - - 8,000 - - - -
112 Foley Catheter T. 16 Buah - - - - - - - 8,000 - - - -
113 Foley Catheter T.18 Buah - - - - - - - 8,000 - - - -
114 Foley Catheter T. 20 Buah - - - - - - - 8,000 - - - -
115 Foley Catheter T. 22 Buah - - - - - - - 8,000 - - - -
116 Foley Catheter T. 24 Buah - - - - - - - 8,000 - - - -
117 Flagystatin Tablet Vagina Tablet - - - - - - - 29,520 - - - -
118 Furosemida Inj i.v i.m 10 mg/ml Vial - - - - - - - 1,850 - - - -
119 Furosemida Tab 40 mg Tablet (30) - (30) 10 - (40) - 88 - 880 - 86,064
120 Formalin Cairan Botol - - - - - - - - - - -
121 Gentamisin Inj 80 mg/ 2ml Ampul - - - - - - - 3,854 - - - -
122 Gentamisin Salf Kulit 0,1 % Tube (15) - (15) 5 - (20) - - - - -
123 Gentamisin Slufat Tetes Mata 0,3 % Botol - - - - - - - 5,020 - - - -
124 Glimepride Tab 4 mg Tablet - - - - - - - 273 - - - -
125 Gentian Violet Larutan 1 % Botol (1) - (1) - - (1) - 5,200 - - - 265,200
126 Gipsonal Gipsum 4 Inchi Buah - - - - - - - 28,500 - - - -
127 Gipsonal Gipsum 6 Inchi Buah - - - - - - - 37,500 - - - -
128 Glibenclamide Tab Tablet (10) - (10) - - (10) - 720 - - - 1,609,200
129 Gliseril Guaiakolat Tab 100 mg/ Guafenisine Tablet (3,083) - (3,083) 806 - (3,889) - 132 - 106,392 - 2,607,264
130 Glukosa Larutan Infus 5 % Steril Botol 42 - 42 2 - 40 - 6,900 - 13,800 - 828,000
131 Glukosa Larutan Infus 10 % Steril Botol - - - - - - - 6,840 - - - -
132 Glukosa Larutan Infus 40 % Steril Botol - - - - - - - - - - -
133 Griseovulvin Tab 125 mg, Micronized Tablet 1,950 - 1,950 20 - 1,930 - 242 - 4,840 - 1,556,544
134 Handscoen S Pcs - - - - - - - - - - -
135 Handscoen M Pcs - - - - - - - - - - -
136 Handscoen L Pcs - - - - - - - - - - -
137 Handscoen No. 6 Pcs - - - - - - - - - - -
138 Handscoen No.7 Pcs - - - - - - - 6,985 - - - -
139 Handscoen No.7,5 Pcs - - - - - - - 6,985 - - - -
140 Hidroklorotiasida ( HCT ) Tab 25 mg Tablet - - - - - - - 194 - - - -
141 Hidrokortison Krim 2,5 mg Tube (4) - (4) 1 - (5) - 2,846 - 2,846 - 947,718
142 Ibuprofen Suspensi Botol - - - - - - - 5,739 - - - -
143 Ibuprofen Tab 200 mg Tablet - - - - - - - - - - -
144 Ibuprofen Tab 400 mg Tablet - - - - - - - - - - -
145 Infusion Set Anak Pcs 150 - 150 - - 150 - 3,500 - - - 1,575,000
146 Infusion Set Dewasa Pcs (70) - (70) - - (70) - 3,200 - - - 768,000
147 Isoniasid ( INH ) Tab 100 mg Tablet - - - - - - - - - - -
148 Isoniasid ( INH ) Tab 300 mg Tablet - - - - - - - 165 - - - -
149 Isosorbid Dinitrat Tab Sublingual 5 mg Tablet - - - - - - - - - - -
150 Kalium Glukonat injeksi 10% (100mg/ml) Ampul - - - - - - - 7,800 - - - -
151 Kalsium Laktat ( Kalk ) Tab 500 mg Tablet 1,977 - 1,977 77 - 1,900 - 62 - 4,774 - 353,400
152 Karbamasepin Tab 200 mg Tablet - - - - - - - 241 - - - -
KAEN-3B Larutan infus (mengandung NaCl 1,75+KCL 1,5gr+ Na
153 Lactat 2,24 gr, Dextrose 27 gr) Botol - - - - - - - 23,500 - - - -

154 Kapas Putih 1000 gr (Kapas Putih 1 Kg) Roll - - - - - - - - - - -


155 Kantung Darah 250 cc Roll - - - - - - - - - - -
156 Kapas Pembalut Absorben 250 Gram Roll - - - - - - - 22,000 - - - -
157 Kapas Berlemak 500 mg Buah (2) - (2) - - (2) - 16,500 - - - 346,500
158 Kasa Roll Panjang Besar 40x80 Cm Buah (1) - (1) - - (1) - 105,000 - - - 630,000
159 Kasa Kompres 40/40 Steril Buah 100 - 100 50 - 50 - 1,600 - 80,000 - 240,000
160 Kasa Pembalut Hidrofil Steril 16 cm x 16 cm Buah - - - - - - - 8,000 - - - -
161 Kasa Pembalut Hidrofil Supergrade 40 cm x 16 cm Buah (6) - (6) - - (6) - 36,960 - - - -

LPLPO/KAB MBD Page 15


1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
162 Kasa Steril 10 cm x 10 cm Buah - - - - - - - - - - -
163 Keterolac Inj 30 mg Ampul - - - - - - - 1,265 - - - -
164 Ketokonazole Tab 200 mg Tablet (170) - (170) 10 - (180) - 311 - 3,110 - 1,138,260
165 Ketokonazole Krim Tube (38) - (38) 1 - (39) - 2,893 - 2,893 - 433,950
166 Kinina Dihidroklorida ( Kina ) Inj 25 %-2ml Ampul - - - - - - - 7,440 - - - -
167 Kuinin Sulfat Tab 222 mg ( H2O ) (Qunine 222 mg) Tablet - - - - - - - 799 - - - 2,090,184
168 Klorpromasin HCL Tab Salut 25 mg Tablet - - - - - - - - - - -
169 Klorpromasin HCL Tab Salut 100 mg Tablet - - - - - - - 179 - - - 107,400
170 Klorpromasin Inj 25 mg/ml-1ml Ampul - - - - - - - 1,550 - - - -
171 Klorpromasin Inj 5 mg/ ml-2ml Ampul - - - - - - - - - - -
172 Kodein HCL ( Kodeina ) Tab 10 mg Tablet - - - - - - - 600 - - - -
173 Klip Plastik 7 x 10 cm Pak - - - - - - - - - - -
174 Klip Plastik 8 x 5 cm Pak - - - - - - - - - - -
175 Kertas pulvis Pak - - - - - - - - - - -
176 Lancet blood Buah - - - - - - - 623 - - - -
177 Lidokain Com, Inj Kombinasi Ampul - - - - - - - 1,433 - - - 257,940
178 Levofloksasin 500 mg Tablet - - - - - - - 520 - - - -
179 Loratadine Tablet 10 mg Tablet - - - - - - - 185 - - - -
180 Loperamide 10 mg Tablet - - - - - - - - - - -
181 Maxiflow Baby (Masker Oksigen) Pcs - - - - - - - - - - -
182 Maxiflow Anak (Masker Oksigen) Pcs - - - - - - - - - - -
183 Maxiflow Dewasa (Masker Oksigen) Pcs - - - - - - - - - - -
184 Masker Botol 20 - 20 - - 20 - 1,226 - - - 73,560
185 Masker Respirator N-95 Buah - - - - - - - - - - -
186 Methilprednisolon Tablet 4 mg Tablet - - - - - - - - - - -
187 Methilergometrin Maleat Inj 0,200 mg/ml-1ml Tablet - - - - - - - 9,900 - - - -
188 Methilergometrin Maleat Tab salut 0,125 mg Tablet - - - - - - - 185 - - - -
189 Meloxicam 7,5 mg Tablet - - - - - - - - - - -
190 Meloxicam 15 mg Tablet - - - - - - - 1,719 - - - -
191 Metformin HCL Tab 500 mg Tablet (10) - (10) - - (10) - 138 - - - 517,500
192 Metformin HCL Tab 850 mg Tablet - - - - - - - 168 - - - -
193 Metoklopramide Tab 10 mg Tablet (114) - (114) 53 - (167) - 117 - 6,201 - 960,687
194 Metronidasol Infus 500 mg/100 ml Botol 12 - 12 - - 12 - 11,547 - - - 415,692
195 Metronidasol Tab 250 mg Tablet - - - - - - - 99 - - - -
196 Metronidasol Tab 500 mg Tablet - - - - - - - 176 - - - -
197 Mikonazol Krim / Salf 2% ( Nitrat ) Tube (12) - (12) 4 - (16) - 4,268 - 17,072 - 166,452
198 Microlax Suppos Suppos - - - - - - - - - - -
199 Mucus Extractor Buah - - - - - - - - - - -
200 Natrium Diklofenak Tab 25 mg Tablet (436) - (436) 180 - (616) - 163 - 29,340 - 1,576,536
201 Natrium Diklofenak Tab 50 mg Tablet - - - - - - - 162 - - - 2,162,700
202 Natrium Klorida Larutan Infus 0,9% Steril Botol 78 - 78 5 - 73 - 6,410 - 32,050 - 1,403,790
203 Nifedipin Tab 10 mg Tablet (60) - (60) 120 - (180) - 219 - 26,280 - 72,270
204 Nistatin 100.000 IU/g Tab Vaginal Tablet - - - - - - - 858 - - - -
205 Nistatin 500.000 IU/ Tab Salut Tablet - - - - - - - 768 - - - -
206 NGT No. 6 Buah - - - - - - - 22,000 - - - -
207 NGT.No. 8 Buah - - - - - - - 22,000 - - - -
208 NGT.No.12 Buah - - - - - - - 22,000 - - - -
209 NGT.No.14 Buah - - - - - - - 22,000 - - - -
210 NGT.No.18 Buah - - - - - - - 22,000 - - - -
211 Obat Batuk Hitam Botol 26 - 26 - - 26 - 2,670 - - - 448,560
212 Omeprasol Tab 20 mg Tablet 810 - 810 94 - 716 - 150 - 14,100 - 322,200
213 Ondansetron Tablet 4 mg Tablet - - - - - - - 1,090 - - - -
214 Obgyn Steril Handscoen Pcs - - - - - - - 1,500 - - - -
215 Oralit/ Garam Oralit Saschet (47) - (47) 16 - (63) - 296 - 4,736 - 1,566,432
216 Objec Glass/Slide Pcs - - - - - - - - - - -
217 Oxibiotic injeksi Vial - - - - - - - - - - -
218 Oxitetrasikllin HCL Inj I.M 50mg/ml-10ml Vial - - - - - - - - - - -
219 Oxitetrasikllin HCL Salep Kulit 3% Tube - - - 1 - (1) - 1,259 - 1,259 - 7,554
220 Oxitetrasikllin Salep Mata 1% Tube - - - - - - - 2,600 - - - -

LPLPO/KAB MBD Page 16


1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
221 Oxitosin Inj 10 IU /ml-1ml (pitogin Injeksi) Ampul - - - - - - - 3,020 - - - -
222 Oxyflow Baby Pcs - - - - - - - - - - -
223 Oxyflow Anak Pcs - - - - - - - - - - -
224 Oxyflow Dewasa Pcs - - - - - - - - - - -
225 Pap Smer Kit S Pcs - - - - - - - - - - -
226 Pap Smer Kit M Pcs - - - - - - - - - - -
227 Pap Smer Kit L Pcs - - - - - - - - - - -
228 Papaverin Inj 40mg/ml Ampul - - - - - - - - - - -
229 Papaverin Tab 40 mg Tablet - - - - - - - - - - -
230 Parasetamol Sirup 120 mg/ml Botol (52) - (52) 1 - (53) - 1,252 - 1,252 - 987,828
231 Parasetamol Tab 500 mg Tablet (2,080) - (2,080) 383 - (2,463) - 66 - 25,278 - 1,310,166
232 Pirantel Pamoat ( Pirantel ) Tab 125 mg Tablet (157) - (157) 4 - (161) - 334 - 1,336 - 164,328
233 Piridoksin HCL ( Vit B6 ) Tab 10 mg Tablet - - - - - - - 154 - - - -
234 Piroxicam Tab 10 mg Tablet (250) - (250) 135 - (385) - 334 - 45,090 - 4,624,230
235 Piroxicam Tab 20 mg Tablet (375) - (375) 115 - (490) - 244 - 28,060 - 183,000
236 Plester 5 Yard x 2 Inch Buah - - - - - - - - - - -
237 Pirasetam Tab 400 mg Tablet - - - - - - - - - - -
238 Pirasinamida Tab 500 mg Tablet - - - - - - - - - - -
239 Prednison Tab 5 mg Tablet 34 - 34 1,415 - (1,381) - 91 - 128,765 - 705,705
240 Primakuin Tab 15 mg Tablet - - - - - - - 175 - - - -
241 Primperan Injeksi Vial - - - - - - - - - - -
242 Prokain Penisillin G Inj 3 Juta IU Ampul - - - - - - - 22,880 - - - -
243 Propanolol HCL ( Propanolol ) Tab 40 mg Tablet - - - - - - - 64 - - - -
244 Ranitidin Inj 25 mg/ml Vial - - - - - - - 1,540 - - - -
245 Ranitidin Tab 150 mg Tablet (770) - (770) 30 - (800) - 121 - 3,630 - 1,985,610
246 Retinol ( Vit A ) Kapsul Lunak 100.000 IU Kapsul - - - - - - - 355 - - - -
247 Retinol ( Vit A ) Kapsul Lunak 200.000 IU Kapsul 950 - 950 - - 950 - 648 - - - 1,846,800
248 Retinol ( Vit A ) Kapsul Lunak 50.000 IU Kapsul - - - - - - - - - - -
249 Ringer Laktat Larutan Infus Steril Botol 55 - 55 3 - 52 - 7,150 - 21,450 - 1,329,900
250 Rivanol Larutan (Etakridin ) 300 ml Botol (5) - (5) - - (5) - 7,200 - - - -
251 Salbutamol Tab 2 mg Tablet - - - - - - - - - - -
252 Salbutamol Tab 4 mg (114) - (114) 32 - (146) - 81 - 2,592 - 169,614
253 Sefadroxil syrup 125mg/ml Botol - - - - - - - 4,581 - - - -
254 Sefadroxil Kapsul 250 mg Kapsul - - - - - - - - - - -
255 Sefadroxil Kapsul 500 mg Kapsul (329) - (329) - - (329) - 587 - - - -
256 Setirizine Tab 10 mg Tablet - - - - - - - 103 - - - -
257 Setirizine Suspensi Botol - - - - - - - 3,192 - - - -
258 Semen Seng Fosfat Serbuk dan Cairan Botol - - - - - - - - - - -
259 Sianokobalamin (Vit B12 ) Inj 500 mcg / ml-1ml vial 100 - 100 - - 100 - 1,335 - - - 400,500
260 Sianokobalamin ( Vit B12 ) Tab 50 mg Tablet 4,280 - 4,280 448 - 3,832 - 53 - 23,744 - 1,200,768
261 Seftriakson Inj 1 g/Vial vial - - - - - - - 5,143 - - - -
262 Sefotaxim Inj 1 g/ Vial vial - - - - - - - 7,700 - - - -
263 Simetidin Tab 200 mg Tablet - - - - - - - - - - -
264 Simvastatin 5 mg Tablet - - - - - - - - - - -
265 Simvastatin Tab 10 mg Tablet (76) - (76) 10 - (86) - 110 - 1,100 - 49,500
266 Siprofloxasin Tab 250 mg Tablet - - - - - - - - - - -
267 Siprofloxasin Tab 500 mg Tablet (120) - (120) 80 - (200) - 305 - 24,400 - 732,000
268 Scabimite Krim Tube - - - - - - - 37,525 - - - -
269 Sofratule (Daryantull) Pcs - - - - - - - - - - -
270 Sohobion Injeksi Ampul (30) - (30) - - (30) - 4,740 - - - -
271 Silk Benang Bedah Sutera + Jarum No.2/0 75 cm Pcs - - - - - - - 4,583 - - - -
272 Silk Benang Bedah Sutera + Jarum No.3/0 75 cm pcs - - - - - - - 4,583 - - - -
273 Sofband Gips 6 Inch roll - - - - - - - 37,500 - - - -
274 Sofband Gips 4 inch Roll - - - - - - - 28,500 - - - -
275 Stik Glukosa Easy Touch Buah - - - - - - - - - - -
276 Stik As. Urat Easy Touch Buah - - - - - - - - - - -
277 Stik Kolesterol Easy Touch Buah - - - - - - - - - - -
278 Tetrasiklin Kapsul 250 mg Kapsul - - - - - - - 193 - - - -
279 Tetrasiklin Kapsul 500 mg Kapsul 2,000 - 2,000 20 - 1,980 - 348 - 6,960 - 2,067,120

LPLPO/KAB MBD Page 17


1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
280 Terramycin Injeksi Vial - - - - - - - 15,300 - - - -
281 Thiamin HCL / Monoitrat (Vit B1) Tab 50 mg Tablet (922) - (922) 581 - (1,503) - 98 - 56,938 - 622,986
282 Thiamin HCL ( Vit B1 ) Inj 100 mg/ml-1ml Vial - - - - - - - - - - -
283 Tranfusi Set (Blood Set) Pcs - - - - - - - 3,600 - - - -
284 Tramadol injeksi Ampul - - - - - - - - - - -
285 Urine Bag pcs (8) - (8) - - (8) - 3,000 - - - 18,000
286 Ultra Sonic Gell Botol - - - - - - - 12,854 - - - -
287 Under Pad 60 cm x 90 Steril With SAP Pcs - - - - - - - - - - -
288 Ventolin injeksi (inhaler) Vial - - - - - - - - - - -
289 Ventolin Nebulizer Ampul - - - - - - - 28,220 - - - -
290 Vaksin Verorab (Anti Rabies) vial - - - - - - - 267,000 - - - -
291 Vitamin B Complex Tab Tablet (1,442) - (1,442) - - (1,442) - 147 - - - -
292 Vitamin B Complex Inj Ampul - - - - - - - 11,273 - - - 338,190
293 Wing Needlee No. 23 pcs - - - - - - - 14,000 - - - -
294 Wing Needlee No. 25 Pcs - - - - - - - 14,000 - - - -
295 Wing Needlee No. 27 Pcs - - - - - - - 14,000 - - - -
296 Yodium Povidon Larutan 10% - 60 ml Botol (5) - (5) - - (5) - 7,532 - - - 112,980
297 Yodium Povidon Larutan 10% - 300 ml Botol - - - - - - - - - - -
298 Yodium Povidon Larutan 10% - 1000 ml Botol (2) - (2) - - (2) - 79,650 - - - 1,672,650
299 Zinc Tablet dispersible 20 mg Tablet (80) - (80) 10 - (90) - 658 - 6,580 - 9,494,940
TOTAL HARGA - 1,527,996 693,035 126,553,824

UMUM
JUMLAH KUNJUNGAN RESEP ASKES JUMLAH
BAYAR TIDAK BAYAR
0 0 …………………………………………. 2019

Mengetahui/Menyetujui; Yang Menyerahkan; Yang Meminta; Yang Menerima;


Kepala Dinas Kesehatan Kabupaten Petugas Gudang Farmasi, Pimpinan Puskesmas, Petugas Puskesmas,
Maluku Barat Daya,

NIP. NIP. NIP. NIP.

LPLPO/KAB MBD Page 18


Kode Puskesmas :
Puskesmas :
Kecamatan : Triwulan II
Puskesmas Pembantu yg Ada ……………. TAHUN : 2019
Kabupaten : MALUKU BARAT DAYA
Provinsi : MALUKU
LAPORAN PEMAKAIAN DAN LEMBAR PERMINTAAN OBAT (LPLPO)

Total Harga Total Harga Total Harga


KODE/N STOK Kadaluwarsa/R STOK Harga Kadaluwarsa/R
NAMA OBAT dan PERBEKALAN KESEHATAN SATUAN PENERIMAAN PERSEDIAAN PEMAKAIAN SISA STOK PERMINTAAN Penerimaan Pemakaian Sisa Stock KET
O. URT AWAL usak APT Satuan (Rp) usak (Rp)
(Rp) (Rp) (Rp)

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
1 Alat Suntik Sekali Pakai 1 CC Buah - - - - - - - 1,100 - - - 3,630,000
2 Alat Suntik Sekali Pakai 2,5 CC Buah - - - - - - - 1,750 - - - -
3 Alat Suntik Sekali Pakai 3 CC Buah - - - - - - - 779 - - - 233,700
4 Alat Suntik Sekali Pakai 5 CC Buah - - - - - - - 968 - - - 2,613,600
5 Alat Suntik Sekali Pakai 10 CC Buah - - - - - - - 1,375 - - - 825,000
6 Alat Suntik Sekali Pakai 20 CC Buah - - - - - - - 1,500 - - - -
7 Abocath ( I.V. Catheter) No. 18 Buah - - - - - - - 3,800 - - - -
8 Abocath (I.V.Catheter) No.20 Buah - - - - - - - 3,800 - - - 2,280,000
9 Abocath (I.V.Catheter) No.22 Buah - - - - - - - 3,800 - - - 2,850,000
10 Abocath (I.V.Catheter) No.24 Buah - - - - - - - 3,800 - - - 2,280,000
11 Abocath (I.V.Catheter) No.26 Buah - - - - - - - 4,100 - - - -
12 Albendasol Tab 400 mg Tablet - - - - - - - 492 - - - -
13 Alkohol 70 % 1000 ml ( Etanol ) Botol (2) 26 24 1 - 23 - 25,000 650,000 25,000 - 2,200,000
14 Alkohol 70 % 100 ml ( Etanol ) Botol - - - - - - - - - - -
15 Allopurinol Tab 100 mg Tablet (110) - (110) 150 - (260) - - - - -
16 Allopurinol Tab 300 mg Tablet - - - - - - - 108 - - - -
17 Ambroxol sirup 15 mg/ml Botol (5) 6 1 12 - (11) - 6,095 36,570 73,140 - 170,660
18 Ambroxol Tab 30 mg Tablet (472) - (472) 950 - (1,422) - 201 - 190,950 - 1,928,193
19 Aminofillin inj 24 mg/ml-10 ml Ampul - - - - - - - 3,280 - - - -
20 Aminofilin Tab 200 mg Tablet - - - - - - - 107 - - - -
21 Amoxicillin Kaplet 250 mg Kaplet - 5,000 5,000 220 - 4,780 - 212 1,060,000 46,640 - 3,040,080
22 Amoxicillin Kapsul 500 mg Kapsul - 5,000 5,000 3,188 - 1,812 - 245 1,225,000 781,060 - 1,762,040
23 Amoxicillin Sirup Kering 125 mg/ 5 ml Botol (10) - (10) 23 - (33) - 2,790 - 64,170 - 1,559,610
24 Ampisillin Kaplet 250 mg Kaplet - - - - - - - - - - -
25 Ampisillin Kaplet 500 mg Kaplet (850) - (850) 26 - (876) - 450 - 11,700 - 2,430,000
26 Ampisillin Serbuk Inj 1.m/ i.v 1000 mg/ml Vial - - - - - - - 10,296 - - - -
27 Ampisillin sirup Kering 125 mg/ 5 ml Botol - - - - - - - - - - -
28 Amlodipin 5 mg tablet tablet - - - 195 - (195) - 99 - 19,305 - 856,350
29 Amlodipin 10 mg Tablet - - - - - - - 83 - - - -
30 Anvomer B6 Tab Tablet - - - - - - - 3,987 - - - -
31 Antasida Doen Tab Kombinasi Tablet (416) - (416) 1,419 - (1,835) - 58 - 82,302 - 2,117,638
32 Antasida Doen II Suspensi Botol (12) - (12) 7 - (19) - 2,257 - 15,799 - -

33 Anti Fungi Doen Kombinasi (Asam Bensoat 3%+As.Salisilat 6% (3) - (3) 18 - (21) - 5,620 - 101,160 - 3,714,820
(Whitefield) Tube
34 Anti Malaria Doen Kombinasi (DHP) Tablet - - - - - - - 2,070 - - - -
35 Aquadest Steril (Air Untuk Injeksi Ampul 25 ml) Ampul - - - - - - - 2,798 - - - -
36 Artemeter injeksi 80 mg/ml Ampul - - - - - - - 26,600 - - - 2,394,000
37 Artesunat Injeksi Ampul - - - - - - - 48,750 - - - -
38 Asam Salisilat 2% + Belerang Endap 4% ( salf 2-4 ) Tube (2) - (2) 10 - (12) - 3,274 - 32,740 - 507,470
39 Asam Askorbat ( Vit C ) Tab 50 mg Tablet - 3,000 3,000 142 - 2,858 - 131 393,000 18,602 - 767,398
40 Asam Folat Tab 1 mg Tablet - - - - - - - 88 - - - -
41 Asam Mefenamat Kapsul 250 mg Kaplet - - - - - - - - - - -
42 Asam Mefenamat Kaplet 500 mg Kaplet (800) - (800) 1,800 - (2,600) - 195 - 351,000 - 937,170
43 Asam Traneksamat injeksi 100 mg/ml Ampul - - - - - - - 2,798 - - - -
44 Aspar - K Tab Tablet - - - - - - - 4,312 - - - -
45 Atropina Sulfat Inj 0,25 mg/ml-1ml Ampul - - - - - - - 1,914 - - - -
46 ATS Injeksi 1500 IU Ampul - - - - - - - 43,183 - - - -

LPLPO/KAB MBD Page 19


1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
47 Asiklovir Krim 5 % Tube - - - - - - - 4,383 - - - -
48 Asiklovir Tab 200 mg Tablet - - - - - - - 236 - - - -
49 Asiklovir Tab 400 mg Tablet - - - 90 - (90) - 414 - 37,260 - 798,192
50 Bedak Salysil Serbuk 2 % Dus - - - - - - - 1,142 - - - -
51 Benzatin Bensil Penisillin 1,2 Juta IU Vial - - - - - - - - - - -

52 Bessi II Sulfat Tab Kombinasi : Besi II sulfat 7H2O 200 mg, Asam Tablet - 3,000 3,000 1,000 - 2,000 - 445 1,335,000 445,000 - 3,066,050
Folat 0,25 mg (Fe = Tambah Darah)
53 Betametason 0,1% Krim Tube - - - 2 - (2) - 1,520 - 3,040 - 483,360
54 Bisoprolol tab Tablet - - - - - - - - - - -
55 Bioplasenton gel Tube (2) - (2) - - (2) - 17,928 - - - -
56 Buscopan Injeksi Ampul - - - - - - - - - - -
57 Bufacetin Salep Kulit Krim Tube - - - - - - - 4,024 - - - -
58 Captopril Tablet 12,5 mg Tablet (110) - (110) 216 - (326) - 87 - 18,792 - 702,525
59 Captopril Tablet 25 mg Tablet - - - - - - - 86 - - - -
60 Catgut Chromic + Jarum No. 2/0 75 cm Pcs - - - - - - - 5,583 - - - -
61 Catgut Chromic + Jarum No. 3/0 75 cm Pcs - - - - - - - 5,583 - - - -
62 Catgut Plain + Jarum No.2/0 75 cm Pcs - - - - - - - 5,583 - - - 803,952
63 Catgut Plain + Jarum No. 3/0 75 cm Pcs - - - - - - - 5,583 - - - -
64 Catapres Injeksi Ampul - - - - - - - 97,220 - - - -
65 Chloramfeniramine Maleat (Ctm) Tablet - - - 2,419 - (2,419) - 26 - 62,894 - 370,188
66 Chloramfenikol Kapsul 250 mg Kapsul (60) - (60) 10 - (70) - 357 - 3,570 - 5,118,666
67 Chloramfenikol Kapsul 500 mg Kapsul - - - - - - - - - - -
68 Chloramfenikol Salf Mata 1% Tube (14) - (14) 19 - (33) - 2,160 - 41,040 - 943,920
69 Chloramfenikol Suspensi 125 mg/5 ml Botol - - - - - - - - - - -
70 Chloramfenikol Tetes Telinga 3 % Botol - - - - - - - 2,590 - - - -
71 Chloramfenikol Salep Kulit 2 % Tube - - - - - - - 4,042 - - - -
72 Clindamiciyn 150 mg Kapsul - - - - - - - 720 - - - 1,080,000
73 Clindamicin 300 mg Kapsul - - - - - - - 893 - - - -
74 Cotrimoxasol Suspensi Botol (3) - (3) 14 - (17) - 2,155 - 30,170 - 642,190

75 Cotrimoxasol Tab kombinasi : Sulfametoksazole 400mg , Tablet (86) - (86) 360 - (446) - 132 - 47,520 - 2,909,280
Trimetroprim 80 mg
76 Dexamethason Inj 5 mg/ml-1 ml Vial (100) - (100) - - (100) - 1,378 - - - 413,400
77 Dexamethason Tab 0,5 mg Tablet (417) - (417) 1,000 - (1,417) - 37 - 37,000 - 294,668
78 Diazepam Inj 5mg/ml-2ml Ampul - - - - - - - 2,150 - - - 193,500
79 Diazepam Tab 2 mg Tablet - - - - - - - 86 - - - -
80 Diazepam Tab 5 mg Tablet - - - 70 - (70) - 115 - 8,050 - 95,450
81 Difenhidramin HCL Inj 10 mg/ml-1 ml Vial - - - - - - - 1,373 - - - -
82 Digoxin Tab 0,25 mg Tablet - - - - - - - 104 - - - 156,000
83 Dimenhidrinat Tablet 50 mg Tablet - - - - 800 (800) - - - - -
84 Doksisiklik Kapsul 100 mg Kapsul - - - - - - - 264 - - - -
85 Domperidon Tab 10 mg Tablet (10) - (10) 86 - (96) - 190 - 16,340 - 500,080
86 Dulcolax Tab Tablet - - - - - - - 166 - - - -
87 Dulcolax Suppos Suppos - - - - - - - 36,200 - - - -
88 Diltiasem HCL Tab 30 mg Tablet - - - - - - - 153 - - - -
89 Efedrin HCL ( Efedrina ) Tab 25 mg Tablet - - - - - - - - - - -
90 Elastic Verband 4 Inchi Buah - - - - - - - 30,250 - - - 907,500
91 Elastic Verband 6 Inchi Buah - - - - - - - - - - -
92 Erlamycetin Tetes Telinga Botol - - - - - - - 5,658 - - - -
93 Epinefrin HCL / Bitartrat ( Adrenalin ) Inj. 0,1%-1ml Ampul - - - - - - - 2,486 - - - -
94 ErLamycetin Tetes Mata Botol (1) - (1) - - (1) - 8,183 - - - 24,549
95 Eritr0misin Kapsul 250 mg Kapsul - - - - - - - 693 - - - -
96 Eritromisin Kapsul 500 mg Kapsul - - - 8 - (8) - 704 - 5,632 - 627,968
97 Eritromisin Sirup 200 mg/5 ml Botol - - - 16 4 (20) - 6,788 - 108,608 27,152 2,260,404
98 Etil Klorida Spray Botol - - - - - - - - - - -
99 Etambutol HCL ( Etambutol ) Tab 250 mg Tablet - - - - - - - - - - -
100 Extension Tube Pcs - - - - - - - - - - -
101 Eugenol cairan Botol - - - - - - - 20,000 - - - -
102 Fenobarbital Inj 50 mg/ml-2ml vial - - - - - - - 2,325 - - - -
103 Fenobarbital Tab 30 mg Tablet - - - - 2,400 (2,400) - 243 - - 583,200 1,166,400

LPLPO/KAB MBD Page 20


1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
104 Fenol Gliseron tetes telinga 10 % Botol - 10 10 1 - 9 - 2,590 25,900 2,590 - 49,210
105 Fitomenadion ( Vit K1 ) Inj 10 mg/ml-1ml Vial - - - - 90 (90) - 4,438 - - 399,420 798,840
106 Fitomenadion ( Vit K1 ) Tab Salut 10 mg Tablet - - - - - - - 890 - - - 15,219,000
107 Foley Catheter T. 6 Botol - - - - - - - 30,000 - - - -
108 Foley Catheter T. 8 Buah - - - - - - - 30,000 - - - -
109 Foley Catheter T.10 Buah - - - - - - - 30,000 - - - -
110 Foley Catheter T.12 Buah - - - - - - - 8,000 - - - -
111 Foley Catheter T.14 Buah - - - - - - - 8,000 - - - -
112 Foley Catheter T. 16 Buah - - - - - - - 8,000 - - - -
113 Foley Catheter T.18 Buah - - - - - - - 8,000 - - - -
114 Foley Catheter T. 20 Buah - - - - - - - 8,000 - - - -
115 Foley Catheter T. 22 Buah - - - - - - - 8,000 - - - -
116 Foley Catheter T. 24 Buah - - - - - - - 8,000 - - - -
117 Flagystatin Tablet Vagina Tablet - - - - - - - 29,520 - - - -
118 Furosemida Inj i.v i.m 10 mg/ml Vial - - - - - - - 1,850 - - - -
119 Furosemida Tab 40 mg Tablet (10) - (10) 20 - (30) - 88 - 1,760 - 89,584
120 Formalin Cairan Botol - - - - - - - - - - -
121 Gentamisin Inj 80 mg/ 2ml Ampul - - - - - - - 3,854 - - - -
122 Gentamisin Salf Kulit 0,1 % Tube (13) - (13) 2 - (15) - - - - -
123 Gentamisin Slufat Tetes Mata 0,3 % Botol - - - - - - - 5,020 - - - -
124 Glimepride Tab 4 mg Tablet - - - - - - - 273 - - - -
125 Gentian Violet Larutan 1 % Botol - - - 1 - (1) - 5,200 - 5,200 - 265,200
126 Gipsonal Gipsum 4 Inchi Buah - - - - - - - 28,500 - - - -
127 Gipsonal Gipsum 6 Inchi Buah - - - - - - - 37,500 - - - -
128 Glibenclamide Tab Tablet (10) - (10) - - (10) - 720 - - - 1,609,200
129 Gliseril Guaiakolat Tab 100 mg/ Guafenisine Tablet (356) - (356) 2,727 - (3,083) - 132 - 359,964 - 3,156,120
130 Glukosa Larutan Infus 5 % Steril Botol - 60 60 18 - 42 - 6,900 414,000 124,200 - 772,800
131 Glukosa Larutan Infus 10 % Steril Botol - - - - - - - 6,840 - - - -
132 Glukosa Larutan Infus 40 % Steril Botol - - - - - - - - - - -
133 Griseovulvin Tab 125 mg, Micronized Tablet (20) 2,000 1,980 30 - 1,950 - 242 484,000 7,260 - 1,578,324
134 Handscoen S Pcs - - - - - - - - - - -
135 Handscoen M Pcs - - - - - - - - - - -
136 Handscoen L Pcs - - - - - - - - - - -
137 Handscoen No. 6 Pcs - - - - - - - - - - -
138 Handscoen No.7 Pcs - - - - - - - 6,985 - - - -
139 Handscoen No.7,5 Pcs - - - - - - - 6,985 - - - -
140 Hidroklorotiasida ( HCT ) Tab 25 mg Tablet - - - - - - - 194 - - - -
141 Hidrokortison Krim 2,5 mg Tube - - - 4 - (4) - 2,846 - 11,384 - 976,178
142 Ibuprofen Suspensi Botol - - - - - - - 5,739 - - - -
143 Ibuprofen Tab 200 mg Tablet - - - - - - - - - - -
144 Ibuprofen Tab 400 mg Tablet - - - - - - - - - - -
145 Infusion Set Anak Pcs - 200 200 50 - 150 - 3,500 700,000 175,000 - 1,225,000
146 Infusion Set Dewasa Pcs - - - 60 10 (70) - 3,200 - 192,000 32,000 1,088,000
147 Isoniasid ( INH ) Tab 100 mg Tablet - - - - - - - - - - -
148 Isoniasid ( INH ) Tab 300 mg Tablet - - - - - - - 165 - - - -
149 Isosorbid Dinitrat Tab Sublingual 5 mg Tablet - - - - - - - - - - -
150 Kalium Glukonat injeksi 10% (100mg/ml) Ampul - - - - - - - 7,800 - - - -
151 Kalsium Laktat ( Kalk ) Tab 500 mg Tablet - 2,320 2,320 343 - 1,977 - 62 143,840 21,266 - 381,672
152 Karbamasepin Tab 200 mg Tablet - - - - - - - 241 - - - -
KAEN-3B Larutan infus (mengandung NaCl 1,75+KCL 1,5gr+ Na
153 Lactat 2,24 gr, Dextrose 27 gr) Botol - - - - - - - 23,500 - - - -

154 Kapas Putih 1000 gr (Kapas Putih 1 Kg) Roll - - - - - - - - - - -


155 Kantung Darah 250 cc Roll - - - - - - - - - - -
156 Kapas Pembalut Absorben 250 Gram Roll - - - - - - - 22,000 - - - -
157 Kapas Berlemak 500 mg Buah (1) - (1) 1 - (2) - 16,500 - 16,500 - 346,500
158 Kasa Roll Panjang Besar 40x80 Cm Buah - - - 1 - (1) - 105,000 - 105,000 - 735,000
159 Kasa Kompres 40/40 Steril Buah - 200 200 100 - 100 - 1,600 320,000 160,000 - 320,000
160 Kasa Pembalut Hidrofil Steril 16 cm x 16 cm Buah - - - - - - - 8,000 - - - -
161 Kasa Pembalut Hidrofil Supergrade 40 cm x 16 cm Buah (2) - (2) 4 - (6) - 36,960 - 147,840 - -

LPLPO/KAB MBD Page 21


1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
162 Kasa Steril 10 cm x 10 cm Buah - - - - - - - - - - -
163 Keterolac Inj 30 mg Ampul - - - - - - - 1,265 - - - -
164 Ketokonazole Tab 200 mg Tablet (30) - (30) 140 - (170) - 311 - 43,540 - 1,200,460
165 Ketokonazole Krim Tube (34) - (34) 4 - (38) - 2,893 - 11,572 - 442,629
166 Kinina Dihidroklorida ( Kina ) Inj 25 %-2ml Ampul - - - - - - - 7,440 - - - -
167 Kuinin Sulfat Tab 222 mg ( H2O ) (Qunine 222 mg) Tablet - - - - - - - 799 - - - 2,090,184
168 Klorpromasin HCL Tab Salut 25 mg Tablet - - - - - - - - - - -
169 Klorpromasin HCL Tab Salut 100 mg Tablet - - - - - - - 179 - - - 107,400
170 Klorpromasin Inj 25 mg/ml-1ml Ampul - - - - - - - 1,550 - - - -
171 Klorpromasin Inj 5 mg/ ml-2ml Ampul - - - - - - - - - - -
172 Kodein HCL ( Kodeina ) Tab 10 mg Tablet - - - - - - - 600 - - - -
173 Klip Plastik 7 x 10 cm Pak - - - - - - - - - - -
174 Klip Plastik 8 x 5 cm Pak - - - - - - - - - - -
175 Kertas pulvis Pak - - - - - - - - - - -
176 Lancet blood Buah - - - - - - - 623 - - - -
177 Lidokain Com, Inj Kombinasi Ampul (30) 30 - - - - - 1,433 42,990 - - 257,940
178 Levofloksasin 500 mg Tablet - - - - - - - 520 - - - -
179 Loratadine Tablet 10 mg Tablet - - - - - - - 185 - - - -
180 Loperamide 10 mg Tablet - - - - - - - - - - -
181 Maxiflow Baby (Masker Oksigen) Pcs - - - - - - - - - - -
182 Maxiflow Anak (Masker Oksigen) Pcs - - - - - - - - - - -
183 Maxiflow Dewasa (Masker Oksigen) Pcs - - - - - - - - - - -
184 Masker Botol - 20 20 - - 20 - 1,226 24,520 - - 73,560
185 Masker Respirator N-95 Buah - - - - - - - - - - -
186 Methilprednisolon Tablet 4 mg Tablet - - - - - - - - - - -
187 Methilergometrin Maleat Inj 0,200 mg/ml-1ml Tablet - - - - - - - 9,900 - - - -
188 Methilergometrin Maleat Tab salut 0,125 mg Tablet - - - - - - - 185 - - - -
189 Meloxicam 7,5 mg Tablet - - - - - - - - - - -
190 Meloxicam 15 mg Tablet - - - - - - - 1,719 - - - -
191 Metformin HCL Tab 500 mg Tablet - - - 10 - (10) - 138 - 1,380 - 517,500
192 Metformin HCL Tab 850 mg Tablet - - - - - - - 168 - - - -
193 Metoklopramide Tab 10 mg Tablet (15) - (15) 99 - (114) - 117 - 11,583 - 986,778
194 Metronidasol Infus 500 mg/100 ml Botol - 24 24 12 - 12 - 11,547 277,128 138,564 - 415,692
195 Metronidasol Tab 250 mg Tablet - - - - - - - 99 - - - -
196 Metronidasol Tab 500 mg Tablet - - - - - - - 176 - - - -
197 Mikonazol Krim / Salf 2% ( Nitrat ) Tube (5) - (5) 7 - (12) - 4,268 - 29,876 - 256,080
198 Microlax Suppos Suppos - - - - - - - - - - -
199 Mucus Extractor Buah - - - - - - - - - - -
200 Natrium Diklofenak Tab 25 mg Tablet (106) - (106) 330 - (436) - 163 - 53,790 - 1,721,606
201 Natrium Diklofenak Tab 50 mg Tablet - - - - - - - 162 - - - 2,162,700
202 Natrium Klorida Larutan Infus 0,9% Steril Botol - 80 80 2 - 78 - 6,410 512,800 12,820 - 1,256,360
203 Nifedipin Tab 10 mg Tablet - - - 60 - (60) - 219 - 13,140 - 159,870
204 Nistatin 100.000 IU/g Tab Vaginal Tablet - - - - - - - 858 - - - -
205 Nistatin 500.000 IU/ Tab Salut Tablet - - - - - - - 768 - - - -
206 NGT No. 6 Buah - - - - - - - 22,000 - - - -
207 NGT.No. 8 Buah - - - - - - - 22,000 - - - -
208 NGT.No.12 Buah - - - - - - - 22,000 - - - -
209 NGT.No.14 Buah - - - - - - - 22,000 - - - -
210 NGT.No.18 Buah - - - - - - - 22,000 - - - -
211 Obat Batuk Hitam Botol - 30 30 4 - 26 - 2,670 80,100 10,680 - 456,570
212 Omeprasol Tab 20 mg Tablet - 900 900 90 - 810 - 150 135,000 13,500 - 256,500
213 Ondansetron Tablet 4 mg Tablet - - - - - - - 1,090 - - - -
214 Obgyn Steril Handscoen Pcs - - - - - - - 1,500 - - - -
215 Oralit/ Garam Oralit Saschet (27) - (27) 20 - (47) - 296 - 5,920 - 1,580,640
216 Objec Glass/Slide Pcs - - - - - - - - - - -
217 Oxibiotic injeksi Vial - - - - - - - - - - -
218 Oxitetrasikllin HCL Inj I.M 50mg/ml-10ml Vial - - - - - - - - - - -
219 Oxitetrasikllin HCL Salep Kulit 3% Tube - - - - - - - 1,259 - - - 11,331
220 Oxitetrasikllin Salep Mata 1% Tube - - - - - - - 2,600 - - - -

LPLPO/KAB MBD Page 22


1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
221 Oxitosin Inj 10 IU /ml-1ml (pitogin Injeksi) Ampul - - - - - - - 3,020 - - - -
222 Oxyflow Baby Pcs - - - - - - - - - - -
223 Oxyflow Anak Pcs - - - - - - - - - - -
224 Oxyflow Dewasa Pcs - - - - - - - - - - -
225 Pap Smer Kit S Pcs - - - - - - - - - - -
226 Pap Smer Kit M Pcs - - - - - - - - - - -
227 Pap Smer Kit L Pcs - - - - - - - - - - -
228 Papaverin Inj 40mg/ml Ampul - - - - - - - - - - -
229 Papaverin Tab 40 mg Tablet - - - - - - - - - - -
230 Parasetamol Sirup 120 mg/ml Botol (12) - (12) 40 - (52) - 1,252 - 50,080 - 1,019,128
231 Parasetamol Tab 500 mg Tablet (971) 3,000 2,029 4,109 - (2,080) - 66 198,000 271,194 - 1,507,440
232 Pirantel Pamoat ( Pirantel ) Tab 125 mg Tablet (325) 200 (125) 32 - (157) - 334 66,800 10,688 - 122,912
233 Piridoksin HCL ( Vit B6 ) Tab 10 mg Tablet - - - - - - - 154 - - - -
234 Piroxicam Tab 10 mg Tablet - - - 250 - (250) - 334 - 83,500 - 4,843,000
235 Piroxicam Tab 20 mg Tablet (70) - (70) 305 - (375) - 244 - 74,420 - 362,340
236 Plester 5 Yard x 2 Inch Buah - - - - - - - - - - -
237 Pirasetam Tab 400 mg Tablet - - - - - - - - - - -
238 Pirasinamida Tab 500 mg Tablet - - - - - - - - - - -
239 Prednison Tab 5 mg Tablet (887) 5,000 4,113 4,079 - 34 - 91 455,000 371,189 - 955,500
240 Primakuin Tab 15 mg Tablet - - - - - - - 175 - - - -
241 Primperan Injeksi Vial - - - - - - - - - - -
242 Prokain Penisillin G Inj 3 Juta IU Ampul - - - - - - - 22,880 - - - -
243 Propanolol HCL ( Propanolol ) Tab 40 mg Tablet - - - - - - - 64 - - - -
244 Ranitidin Inj 25 mg/ml Vial - - - - - - - 1,540 - - - -
245 Ranitidin Tab 150 mg Tablet (130) - (130) 640 - (770) - 121 - 77,440 - 2,073,940
246 Retinol ( Vit A ) Kapsul Lunak 100.000 IU Kapsul - 1,000 1,000 - 1,000 - - 355 355,000 - 355,000 355,000
247 Retinol ( Vit A ) Kapsul Lunak 200.000 IU Kapsul - 1,000 1,000 50 - 950 - 648 648,000 32,400 - 1,263,600
248 Retinol ( Vit A ) Kapsul Lunak 50.000 IU Kapsul - - - - - - - - - - -
249 Ringer Laktat Larutan Infus Steril Botol (4) 80 76 21 - 55 - 7,150 572,000 150,150 - 1,294,150
250 Rivanol Larutan (Etakridin ) 300 ml Botol (1) - (1) 4 - (5) - 7,200 - 28,800 - 14,400
251 Salbutamol Tab 2 mg Tablet - - - - - - - - - - -
252 Salbutamol Tab 4 mg (60) 100 40 154 - (114) - 81 8,100 12,474 - 177,228
253 Sefadroxil syrup 125mg/ml Botol - - - - - - - 4,581 - - - -
254 Sefadroxil Kapsul 250 mg Kapsul - - - - - - - - - - -
255 Sefadroxil Kapsul 500 mg Kapsul (246) - (246) 83 - (329) - 587 - 48,721 - -
256 Setirizine Tab 10 mg Tablet - - - - - - - 103 - - - -
257 Setirizine Suspensi Botol - - - - - - - 3,192 - - - -
258 Semen Seng Fosfat Serbuk dan Cairan Botol - - - - - - - - - - -
259 Sianokobalamin (Vit B12 ) Inj 500 mcg / ml-1ml vial - 100 100 - - 100 - 1,335 133,500 - - 267,000
260 Sianokobalamin ( Vit B12 ) Tab 50 mg Tablet (30) 5,000 4,970 690 - 4,280 - 53 265,000 36,570 - 1,300,620
261 Seftriakson Inj 1 g/Vial vial - - - - - - - 5,143 - - - -
262 Sefotaxim Inj 1 g/ Vial vial - - - - - - - 7,700 - - - -
263 Simetidin Tab 200 mg Tablet - - - - - - - - - - -
264 Simvastatin 5 mg Tablet - - - - - - - - - - -
265 Simvastatin Tab 10 mg Tablet (10) - (10) 66 - (76) - 110 - 7,260 - 61,160
266 Siprofloxasin Tab 250 mg Tablet - - - - - - - - - - -
267 Siprofloxasin Tab 500 mg Tablet (20) - (20) 100 - (120) - 305 - 30,500 - 844,850
268 Scabimite Krim Tube - - - - - - - 37,525 - - - -
269 Sofratule (Daryantull) Pcs - - - - - - - - - - -
270 Sohobion Injeksi Ampul (10) - (10) 20 - (30) - 4,740 - 94,800 - 94,800
271 Silk Benang Bedah Sutera + Jarum No.2/0 75 cm Pcs - - - - - - - 4,583 - - - -
272 Silk Benang Bedah Sutera + Jarum No.3/0 75 cm pcs - - - - - - - 4,583 - - - -
273 Sofband Gips 6 Inch roll - - - - - - - 37,500 - - - -
274 Sofband Gips 4 inch Roll - - - - - - - 28,500 - - - -
275 Stik Glukosa Easy Touch Buah - - - - - - - - - - -
276 Stik As. Urat Easy Touch Buah - - - - - - - - - - -
277 Stik Kolesterol Easy Touch Buah - - - - - - - - - - -
278 Tetrasiklin Kapsul 250 mg Kapsul - - - - - - - 193 - - - -
279 Tetrasiklin Kapsul 500 mg Kapsul - 2,000 2,000 - - 2,000 - 348 696,000 - - 1,392,000

LPLPO/KAB MBD Page 23


1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
280 Terramycin Injeksi Vial - - - - - - - 15,300 - - - -
281 Thiamin HCL / Monoitrat (Vit B1) Tab 50 mg Tablet (322) - (322) 600 - (922) - 98 - 58,800 - 851,620
282 Thiamin HCL ( Vit B1 ) Inj 100 mg/ml-1ml Vial - - - - - - - - - - -
283 Tranfusi Set (Blood Set) Pcs - - - - - - - 3,600 - - - -
284 Tramadol injeksi Ampul - - - - - - - - - - -
285 Urine Bag pcs - - - 8 - (8) - 3,000 - 24,000 - 45,000
286 Ultra Sonic Gell Botol - - - - - - - 12,854 - - - -
287 Under Pad 60 cm x 90 Steril With SAP Pcs - - - - - - - - - - -
288 Ventolin injeksi (inhaler) Vial - - - - - - - - - - -
289 Ventolin Nebulizer Ampul - - - - - - - 28,220 - - - -
290 Vaksin Verorab (Anti Rabies) vial - - - - - - - 267,000 - - - -
291 Vitamin B Complex Tab Tablet (652) - (652) 790 - (1,442) - 147 - 116,130 - -
292 Vitamin B Complex Inj Ampul - - - - - - - 11,273 - - - 338,190
293 Wing Needlee No. 23 pcs - - - - - - - 14,000 - - - -
294 Wing Needlee No. 25 Pcs - - - - - - - 14,000 - - - -
295 Wing Needlee No. 27 Pcs - - - - - - - 14,000 - - - -
296 Yodium Povidon Larutan 10% - 60 ml Botol (1) - (1) 4 - (5) - 7,532 - 30,128 - 135,576
297 Yodium Povidon Larutan 10% - 300 ml Botol - - - - - - - - - - -
298 Yodium Povidon Larutan 10% - 1000 ml Botol (1) - (1) 1 - (2) - 79,650 - 79,650 - 1,752,300
299 Zinc Tablet dispersible 20 mg Tablet (3) - (3) 77 - (80) - 658 - 50,666 - 9,584,428
TOTAL HARGA 11,257,248 6,094,373 1,396,772 135,876,581

UMUM
JUMLAH KUNJUNGAN RESEP ASKES JUMLAH
BAYAR TIDAK BAYAR
0 0 …………………………………………. 2019

Mengetahui/Menyetujui; Yang Menyerahkan; Yang Meminta; Yang Menerima;


Kepala Dinas Kesehatan Kabupaten Petugas Gudang Farmasi, Pimpinan Puskesmas, Petugas Puskesmas,
Maluku Barat Daya,

NIP. NIP. NIP. NIP.

LPLPO/KAB MBD Page 24


Kode Puskesmas :
Puskesmas :
Kecamatan : Triwulan I
Puskesmas Pembantu yg Ada ……………. TAHUN : 2019
Kabupaten : MALUKU BARAT DAYA
Provinsi : MALUKU
LAPORAN PEMAKAIAN DAN LEMBAR PERMINTAAN OBAT (LPLPO)

Total Harga Total Harga Total Harga


KODE/N STOK Kadaluwarsa/R STOK Harga Kadaluwarsa/R
NAMA OBAT dan PERBEKALAN KESEHATAN SATUAN PENERIMAAN PERSEDIAAN PEMAKAIAN SISA STOK PERMINTAAN Penerimaan Pemakaian Sisa Stock KET
O. URT AWAL usak APT Satuan (Rp) usak (Rp)
(Rp) (Rp) (Rp)

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
1 Alat Suntik Sekali Pakai 1 CC Buah - - - - - - - 1,100 - - - 1,210,000
2 Alat Suntik Sekali Pakai 2,5 CC Buah - - - - - - - 1,750 - - - -
3 Alat Suntik Sekali Pakai 3 CC Buah - - - - - - - 779 - - - 77,900
4 Alat Suntik Sekali Pakai 5 CC Buah - - - - - - - 968 - - - 871,200
5 Alat Suntik Sekali Pakai 10 CC Buah - - - - - - - 1,375 - - - 275,000
6 Alat Suntik Sekali Pakai 20 CC Buah - - - - - - - 1,500 - - - -
7 Abocath ( I.V. Catheter) No. 18 Buah - - - - - - - 3,800 - - - -
8 Abocath (I.V.Catheter) No.20 Buah - - - - - - - 3,800 - - - 760,000
9 Abocath (I.V.Catheter) No.22 Buah - - - - - - - 3,800 - - - 950,000
10 Abocath (I.V.Catheter) No.24 Buah - - - - - - - 3,800 - - - 760,000
11 Abocath (I.V.Catheter) No.26 Buah - - - - - - - 4,100 - - - -
12 Albendasol Tab 400 mg Tablet - - - - - - - 492 - - - -
13 Alkohol 70 % 1000 ml ( Etanol ) Botol - - - 2 - (2) - 25,000 - 50,000 - 150,000
14 Alkohol 70 % 100 ml ( Etanol ) Botol - - - - - - - - - - -
15 Allopurinol Tab 100 mg Tablet - - - 110 - (110) - - - - -
16 Allopurinol Tab 300 mg Tablet - - - - - - - 108 - - - -
17 Ambroxol sirup 15 mg/ml Botol - - - 5 - (5) - 6,095 - 30,475 - 91,425
18 Ambroxol Tab 30 mg Tablet - - - 472 - (472) - 201 - 94,872 - 823,899
19 Aminofillin inj 24 mg/ml-10 ml Ampul - - - - - - - 3,280 - - - -
20 Aminofilin Tab 200 mg Tablet - - - - - - - 107 - - - -
21 Amoxicillin Kaplet 250 mg Kaplet - - - - - - - 212 - - - -
22 Amoxicillin Kapsul 500 mg Kapsul - - - - - - - 245 - - - -
23 Amoxicillin Sirup Kering 125 mg/ 5 ml Botol - - - 10 - (10) - 2,790 - 27,900 - 571,950
24 Ampisillin Kaplet 250 mg Kaplet - - - - - - - - - - -
25 Ampisillin Kaplet 500 mg Kaplet - - - 850 - (850) - 450 - 382,500 - 821,700
26 Ampisillin Serbuk Inj 1.m/ i.v 1000 mg/ml Vial - - - - - - - 10,296 - - - -
27 Ampisillin sirup Kering 125 mg/ 5 ml Botol - - - - - - - - - - -
28 Amlodipin 5 mg tablet tablet - - - - - - - 99 - - - 297,000
29 Amlodipin 10 mg Tablet - - - - - - - 83 - - - -
30 Anvomer B6 Tab Tablet - - - - - - - 3,987 - - - -
31 Antasida Doen Tab Kombinasi Tablet - - - 416 - (416) - 58 - 24,128 - 770,240
32 Antasida Doen II Suspensi Botol - - - 12 - (12) - 2,257 - 27,084 - 15,799

33 Anti Fungi Doen Kombinasi (Asam Bensoat 3%+As.Salisilat 6% - - - 3 - (3) - 5,620 - 16,860 - 1,315,080
(Whitefield) Tube
34 Anti Malaria Doen Kombinasi (DHP) Tablet - - - - - - - 2,070 - - - -
35 Aquadest Steril (Air Untuk Injeksi Ampul 25 ml) Ampul - - - - - - - 2,798 - - - -
36 Artemeter injeksi 80 mg/ml Ampul - - - - - - - 26,600 - - - 798,000
37 Artesunat Injeksi Ampul - - - - - - - 48,750 - - - -
38 Asam Salisilat 2% + Belerang Endap 4% ( salf 2-4 ) Tube - - - 2 - (2) - 3,274 - 6,548 - 196,440
39 Asam Askorbat ( Vit C ) Tab 50 mg Tablet - - - - - - - 131 - - - -
40 Asam Folat Tab 1 mg Tablet - - - - - - - 88 - - - -
41 Asam Mefenamat Kapsul 250 mg Kaplet - - - - - - - - - - -
42 Asam Mefenamat Kaplet 500 mg Kaplet - - - 800 - (800) - 195 - 156,000 - 585,000
43 Asam Traneksamat injeksi 100 mg/ml Ampul - - - - - - - 2,798 - - - -
44 Aspar - K Tab Tablet - - - - - - - 4,312 - - - -
45 Atropina Sulfat Inj 0,25 mg/ml-1ml Ampul - - - - - - - 1,914 - - - -
46 ATS Injeksi 1500 IU Ampul - - - - - - - 43,183 - - - -

LPLPO/KAB MBD Page 25


1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
47 Asiklovir Krim 5 % Tube - - - - - - - 4,383 - - - -
48 Asiklovir Tab 200 mg Tablet - - - - - - - 236 - - - -
49 Asiklovir Tab 400 mg Tablet - - - - - - - 414 - - - 291,456
50 Bedak Salysil Serbuk 2 % Dus - - - - - - - 1,142 - - - -
51 Benzatin Bensil Penisillin 1,2 Juta IU Vial - - - - - - - - - - -

52 Bessi II Sulfat Tab Kombinasi : Besi II sulfat 7H2O 200 mg, Asam Tablet - - - - - - - 445 - - - -
Folat 0,25 mg (Fe = Tambah Darah)
53 Betametason 0,1% Krim Tube - - - - - - - 1,520 - - - 162,640
54 Bisoprolol tab Tablet - - - - - - - - - - -
55 Bioplasenton gel Tube - - - 2 - (2) - 17,928 - 35,856 - -
56 Buscopan Injeksi Ampul - - - - - - - - - - -
57 Bufacetin Salep Kulit Krim Tube - - - - - - - 4,024 - - - -
58 Captopril Tablet 12,5 mg Tablet - - - 110 - (110) - 87 - 9,570 - 248,820
59 Captopril Tablet 25 mg Tablet - - - - - - - 86 - - - -
60 Catgut Chromic + Jarum No. 2/0 75 cm Pcs - - - - - - - 5,583 - - - -
61 Catgut Chromic + Jarum No. 3/0 75 cm Pcs - - - - - - - 5,583 - - - -
62 Catgut Plain + Jarum No.2/0 75 cm Pcs - - - - - - - 5,583 - - - 267,984
63 Catgut Plain + Jarum No. 3/0 75 cm Pcs - - - - - - - 5,583 - - - -
64 Catapres Injeksi Ampul - - - - - - - 97,220 - - - -
65 Chloramfeniramine Maleat (Ctm) Tablet - - - - - - - 26 - - - 174,200
66 Chloramfenikol Kapsul 250 mg Kapsul - - - 60 - (60) - 357 - 21,420 - 1,708,602
67 Chloramfenikol Kapsul 500 mg Kapsul - - - - - - - - - - -
68 Chloramfenikol Salf Mata 1% Tube - - - 14 - (14) - 2,160 - 30,240 - 336,960
69 Chloramfenikol Suspensi 125 mg/5 ml Botol - - - - - - - - - - -
70 Chloramfenikol Tetes Telinga 3 % Botol - - - - - - - 2,590 - - - -
71 Chloramfenikol Salep Kulit 2 % Tube - - - - - - - 4,042 - - - -
72 Clindamiciyn 150 mg Kapsul - - - - - - - 720 - - - 360,000
73 Clindamicin 300 mg Kapsul - - - - - - - 893 - - - -
74 Cotrimoxasol Suspensi Botol - - - 3 - (3) - 2,155 - 6,465 - 239,205

75 Cotrimoxasol Tab kombinasi : Sulfametoksazole 400mg , Tablet - - - 86 - (86) - 132 - 11,352 - 1,008,480
Trimetroprim 80 mg
76 Dexamethason Inj 5 mg/ml-1 ml Vial - - - 100 - (100) - 1,378 - 137,800 - 137,800
77 Dexamethason Tab 0,5 mg Tablet - - - 417 - (417) - 37 - 15,429 - 125,800
78 Diazepam Inj 5mg/ml-2ml Ampul - - - - - - - 2,150 - - - 64,500
79 Diazepam Tab 2 mg Tablet - - - - - - - 86 - - - -
80 Diazepam Tab 5 mg Tablet - - - - - - - 115 - - - 34,500
81 Difenhidramin HCL Inj 10 mg/ml-1 ml Vial - - - - - - - 1,373 - - - -
82 Digoxin Tab 0,25 mg Tablet - - - - - - - 104 - - - 52,000
83 Dimenhidrinat Tablet 50 mg Tablet - - - - - - - - - - -
84 Doksisiklik Kapsul 100 mg Kapsul - - - - - - - 264 - - - -
85 Domperidon Tab 10 mg Tablet - - - 10 - (10) - 190 - 1,900 - 180,500
86 Dulcolax Tab Tablet - - - - - - - 166 - - - -
87 Dulcolax Suppos Suppos - - - - - - - 36,200 - - - -
88 Diltiasem HCL Tab 30 mg Tablet - - - - - - - 153 - - - -
89 Efedrin HCL ( Efedrina ) Tab 25 mg Tablet - - - - - - - - - - -
90 Elastic Verband 4 Inchi Buah - - - - - - - 30,250 - - - 302,500
91 Elastic Verband 6 Inchi Buah - - - - - - - - - - -
92 Erlamycetin Tetes Telinga Botol - - - - - - - 5,658 - - - -
93 Epinefrin HCL / Bitartrat ( Adrenalin ) Inj. 0,1%-1ml Ampul - - - - - - - 2,486 - - - -
94 ErLamycetin Tetes Mata Botol - - - 1 - (1) - 8,183 - 8,183 - 8,183
95 Eritr0misin Kapsul 250 mg Kapsul - - - - - - - 693 - - - -
96 Eritromisin Kapsul 500 mg Kapsul - - - - - - - 704 - - - 211,200
97 Eritromisin Sirup 200 mg/5 ml Botol - - - - - - - 6,788 - - - 814,560
98 Etil Klorida Spray Botol - - - - - - - - - - -
99 Etambutol HCL ( Etambutol ) Tab 250 mg Tablet - - - - - - - - - - -
100 Extension Tube Pcs - - - - - - - - - - -
101 Eugenol cairan Botol - - - - - - - 20,000 - - - -
102 Fenobarbital Inj 50 mg/ml-2ml vial - - - - - - - 2,325 - - - -
103 Fenobarbital Tab 30 mg Tablet - - - - - - - 243 - - - 583,200

LPLPO/KAB MBD Page 26


1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
104 Fenol Gliseron tetes telinga 10 % Botol - - - - - - - 2,590 - - - -
105 Fitomenadion ( Vit K1 ) Inj 10 mg/ml-1ml Vial - - - - - - - 4,438 - - - 399,420
106 Fitomenadion ( Vit K1 ) Tab Salut 10 mg Tablet - - - - - - - 890 - - - 5,073,000
107 Foley Catheter T. 6 Botol - - - - - - - 30,000 - - - -
108 Foley Catheter T. 8 Buah - - - - - - - 30,000 - - - -
109 Foley Catheter T.10 Buah - - - - - - - 30,000 - - - -
110 Foley Catheter T.12 Buah - - - - - - - 8,000 - - - -
111 Foley Catheter T.14 Buah - - - - - - - 8,000 - - - -
112 Foley Catheter T. 16 Buah - - - - - - - 8,000 - - - -
113 Foley Catheter T.18 Buah - - - - - - - 8,000 - - - -
114 Foley Catheter T. 20 Buah - - - - - - - 8,000 - - - -
115 Foley Catheter T. 22 Buah - - - - - - - 8,000 - - - -
116 Foley Catheter T. 24 Buah - - - - - - - 8,000 - - - -
117 Flagystatin Tablet Vagina Tablet - - - - - - - 29,520 - - - -
118 Furosemida Inj i.v i.m 10 mg/ml Vial - - - - - - - 1,850 - - - -
119 Furosemida Tab 40 mg Tablet - - - 10 - (10) - 88 - 880 - 31,328
120 Formalin Cairan Botol - - - - - - - - - - -
121 Gentamisin Inj 80 mg/ 2ml Ampul - - - - - - - 3,854 - - - -
122 Gentamisin Salf Kulit 0,1 % Tube - - - 13 - (13) - - - - -
123 Gentamisin Slufat Tetes Mata 0,3 % Botol - - - - - - - 5,020 - - - -
124 Glimepride Tab 4 mg Tablet - - - - - - - 273 - - - -
125 Gentian Violet Larutan 1 % Botol - - - - - - - 5,200 - - - 93,600
126 Gipsonal Gipsum 4 Inchi Buah - - - - - - - 28,500 - - - -
127 Gipsonal Gipsum 6 Inchi Buah - - - - - - - 37,500 - - - -
128 Glibenclamide Tab Tablet - - - 10 - (10) - 720 - 7,200 - 536,400
129 Gliseril Guaiakolat Tab 100 mg/ Guafenisine Tablet - - - 356 - (356) - 132 - 46,992 - 1,335,444
130 Glukosa Larutan Infus 5 % Steril Botol - - - - - - - 6,900 - - - -
131 Glukosa Larutan Infus 10 % Steril Botol - - - - - - - 6,840 - - - -
132 Glukosa Larutan Infus 40 % Steril Botol - - - - - - - - - - -
133 Griseovulvin Tab 125 mg, Micronized Tablet - - - 20 - (20) - 242 - 4,840 - 46,948
134 Handscoen S Pcs - - - - - - - - - - -
135 Handscoen M Pcs - - - - - - - - - - -
136 Handscoen L Pcs - - - - - - - - - - -
137 Handscoen No. 6 Pcs - - - - - - - - - - -
138 Handscoen No.7 Pcs - - - - - - - 6,985 - - - -
139 Handscoen No.7,5 Pcs - - - - - - - 6,985 - - - -
140 Hidroklorotiasida ( HCT ) Tab 25 mg Tablet - - - - - - - 194 - - - -
141 Hidrokortison Krim 2,5 mg Tube - - - - - - - 2,846 - - - 330,136
142 Ibuprofen Suspensi Botol - - - - - - - 5,739 - - - -
143 Ibuprofen Tab 200 mg Tablet - - - - - - - - - - -
144 Ibuprofen Tab 400 mg Tablet - - - - - - - - - - -
145 Infusion Set Anak Pcs - - - - - - - 3,500 - - - -
146 Infusion Set Dewasa Pcs - - - - - - - 3,200 - - - 480,000
147 Isoniasid ( INH ) Tab 100 mg Tablet - - - - - - - - - - -
148 Isoniasid ( INH ) Tab 300 mg Tablet - - - - - - - 165 - - - -
149 Isosorbid Dinitrat Tab Sublingual 5 mg Tablet - - - - - - - - - - -
150 Kalium Glukonat injeksi 10% (100mg/ml) Ampul - - - - - - - 7,800 - - - -
151 Kalsium Laktat ( Kalk ) Tab 500 mg Tablet - - - - - - - 62 - - - -
152 Karbamasepin Tab 200 mg Tablet - - - - - - - 241 - - - -
KAEN-3B Larutan infus (mengandung NaCl 1,75+KCL 1,5gr+ Na
153 Lactat 2,24 gr, Dextrose 27 gr) Botol - - - - - - - 23,500 - - - -

154 Kapas Putih 1000 gr (Kapas Putih 1 Kg) Roll - - - - - - - - - - -


155 Kantung Darah 250 cc Roll - - - - - - - - - - -
156 Kapas Pembalut Absorben 250 Gram Roll - - - - - - - 22,000 - - - -
157 Kapas Berlemak 500 mg Buah - - - 1 - (1) - 16,500 - 16,500 - 132,000
158 Kasa Roll Panjang Besar 40x80 Cm Buah - - - - - - - 105,000 - - - 315,000
159 Kasa Kompres 40/40 Steril Buah - - - - - - - 1,600 - - - -
160 Kasa Pembalut Hidrofil Steril 16 cm x 16 cm Buah - - - - - - - 8,000 - - - -
161 Kasa Pembalut Hidrofil Supergrade 40 cm x 16 cm Buah - - - 2 - (2) - 36,960 - 73,920 - 147,840

LPLPO/KAB MBD Page 27


1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
162 Kasa Steril 10 cm x 10 cm Buah - - - - - - - - - - -
163 Keterolac Inj 30 mg Ampul - - - - - - - 1,265 - - - -
164 Ketokonazole Tab 200 mg Tablet - - - 30 - (30) - 311 - 9,330 - 426,070
165 Ketokonazole Krim Tube - - - 34 - (34) - 2,893 - 98,362 - 159,115
166 Kinina Dihidroklorida ( Kina ) Inj 25 %-2ml Ampul - - - - - - - 7,440 - - - -
167 Kuinin Sulfat Tab 222 mg ( H2O ) (Qunine 222 mg) Tablet - - - - - - - 799 - - - 696,728
168 Klorpromasin HCL Tab Salut 25 mg Tablet - - - - - - - - - - -
169 Klorpromasin HCL Tab Salut 100 mg Tablet - - - - - - - 179 - - - 35,800
170 Klorpromasin Inj 25 mg/ml-1ml Ampul - - - - - - - 1,550 - - - -
171 Klorpromasin Inj 5 mg/ ml-2ml Ampul - - - - - - - - - - -
172 Kodein HCL ( Kodeina ) Tab 10 mg Tablet - - - - - - - 600 - - - -
173 Klip Plastik 7 x 10 cm Pak - - - - - - - - - - -
174 Klip Plastik 8 x 5 cm Pak - - - - - - - - - - -
175 Kertas pulvis Pak - - - - - - - - - - -
176 Lancet blood Buah - - - - - - - 623 - - - -
177 Lidokain Com, Inj Kombinasi Ampul - - - 30 - (30) - 1,433 - 42,990 - 42,990
178 Levofloksasin 500 mg Tablet - - - - - - - 520 - - - -
179 Loratadine Tablet 10 mg Tablet - - - - - - - 185 - - - -
180 Loperamide 10 mg Tablet - - - - - - - - - - -
181 Maxiflow Baby (Masker Oksigen) Pcs - - - - - - - - - - -
182 Maxiflow Anak (Masker Oksigen) Pcs - - - - - - - - - - -
183 Maxiflow Dewasa (Masker Oksigen) Pcs - - - - - - - - - - -
184 Masker Botol - - - - - - - 1,226 - - - -
185 Masker Respirator N-95 Buah - - - - - - - - - - -
186 Methilprednisolon Tablet 4 mg Tablet - - - - - - - - - - -
187 Methilergometrin Maleat Inj 0,200 mg/ml-1ml Tablet - - - - - - - 9,900 - - - -
188 Methilergometrin Maleat Tab salut 0,125 mg Tablet - - - - - - - 185 - - - -
189 Meloxicam 7,5 mg Tablet - - - - - - - - - - -
190 Meloxicam 15 mg Tablet - - - - - - - 1,719 - - - -
191 Metformin HCL Tab 500 mg Tablet - - - - - - - 138 - - - 173,880
192 Metformin HCL Tab 850 mg Tablet - - - - - - - 168 - - - -
193 Metoklopramide Tab 10 mg Tablet - - - 15 - (15) - 117 - 1,755 - 338,013
194 Metronidasol Infus 500 mg/100 ml Botol - - - - - - - 11,547 - - - -
195 Metronidasol Tab 250 mg Tablet - - - - - - - 99 - - - -
196 Metronidasol Tab 500 mg Tablet - - - - - - - 176 - - - -
197 Mikonazol Krim / Salf 2% ( Nitrat ) Tube - - - 5 - (5) - 4,268 - 21,340 - 102,432
198 Microlax Suppos Suppos - - - - - - - - - - -
199 Mucus Extractor Buah - - - - - - - - - - -
200 Natrium Diklofenak Tab 25 mg Tablet - - - 106 - (106) - 163 - 17,278 - 608,642
201 Natrium Diklofenak Tab 50 mg Tablet - - - - - - - 162 - - - 720,900
202 Natrium Klorida Larutan Infus 0,9% Steril Botol - - - - - - - 6,410 - - - -
203 Nifedipin Tab 10 mg Tablet - - - - - - - 219 - - - 63,510
204 Nistatin 100.000 IU/g Tab Vaginal Tablet - - - - - - - 858 - - - -
205 Nistatin 500.000 IU/ Tab Salut Tablet - - - - - - - 768 - - - -
206 NGT No. 6 Buah - - - - - - - 22,000 - - - -
207 NGT.No. 8 Buah - - - - - - - 22,000 - - - -
208 NGT.No.12 Buah - - - - - - - 22,000 - - - -
209 NGT.No.14 Buah - - - - - - - 22,000 - - - -
210 NGT.No.18 Buah - - - - - - - 22,000 - - - -
211 Obat Batuk Hitam Botol - - - - - - - 2,670 - - - 80,100
212 Omeprasol Tab 20 mg Tablet - - - - - - - 150 - - - -
213 Ondansetron Tablet 4 mg Tablet - - - - - - - 1,090 - - - -
214 Obgyn Steril Handscoen Pcs - - - - - - - 1,500 - - - -
215 Oralit/ Garam Oralit Saschet - - - 27 - (27) - 296 - 7,992 - 532,800
216 Objec Glass/Slide Pcs - - - - - - - - - - -
217 Oxibiotic injeksi Vial - - - - - - - - - - -
218 Oxitetrasikllin HCL Inj I.M 50mg/ml-10ml Vial - - - - - - - - - - -
219 Oxitetrasikllin HCL Salep Kulit 3% Tube - - - - - - - 1,259 - - - 3,777
220 Oxitetrasikllin Salep Mata 1% Tube - - - - - - - 2,600 - - - -

LPLPO/KAB MBD Page 28


1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
221 Oxitosin Inj 10 IU /ml-1ml (pitogin Injeksi) Ampul - - - - - - - 3,020 - - - -
222 Oxyflow Baby Pcs - - - - - - - - - - -
223 Oxyflow Anak Pcs - - - - - - - - - - -
224 Oxyflow Dewasa Pcs - - - - - - - - - - -
225 Pap Smer Kit S Pcs - - - - - - - - - - -
226 Pap Smer Kit M Pcs - - - - - - - - - - -
227 Pap Smer Kit L Pcs - - - - - - - - - - -
228 Papaverin Inj 40mg/ml Ampul - - - - - - - - - - -
229 Papaverin Tab 40 mg Tablet - - - - - - - - - - -
230 Parasetamol Sirup 120 mg/ml Botol - - - 12 - (12) - 1,252 - 15,024 - 380,608
231 Parasetamol Tab 500 mg Tablet - - - 971 - (971) - 66 - 64,086 - 535,194
232 Pirantel Pamoat ( Pirantel ) Tab 125 mg Tablet - - - - 325 (325) - 334 - - 108,550 -
233 Piridoksin HCL ( Vit B6 ) Tab 10 mg Tablet - - - - - - - 154 - - - -
234 Piroxicam Tab 10 mg Tablet - - - - - - - 334 - - - 1,670,000
235 Piroxicam Tab 20 mg Tablet - - - 70 - (70) - 244 - 17,080 - 163,480
236 Plester 5 Yard x 2 Inch Buah - - - - - - - - - - -
237 Pirasetam Tab 400 mg Tablet - - - - - - - - - - -
238 Pirasinamida Tab 500 mg Tablet - - - - - - - - - - -
239 Prednison Tab 5 mg Tablet - - - 887 - (887) - 91 - 80,717 - 280,189
240 Primakuin Tab 15 mg Tablet - - - - - - - 175 - - - -
241 Primperan Injeksi Vial - - - - - - - - - - -
242 Prokain Penisillin G Inj 3 Juta IU Ampul - - - - - - - 22,880 - - - -
243 Propanolol HCL ( Propanolol ) Tab 40 mg Tablet - - - - - - - 64 - - - -
244 Ranitidin Inj 25 mg/ml Vial - - - - - - - 1,540 - - - -
245 Ranitidin Tab 150 mg Tablet - - - 130 - (130) - 121 - 15,730 - 742,940
246 Retinol ( Vit A ) Kapsul Lunak 100.000 IU Kapsul - - - - - - - 355 - - - -
247 Retinol ( Vit A ) Kapsul Lunak 200.000 IU Kapsul - - - - - - - 648 - - - -
248 Retinol ( Vit A ) Kapsul Lunak 50.000 IU Kapsul - - - - - - - - - - -
249 Ringer Laktat Larutan Infus Steril Botol - - - 4 - (4) - 7,150 - 28,600 - 42,900
250 Rivanol Larutan (Etakridin ) 300 ml Botol - - - 1 - (1) - 7,200 - 7,200 - 28,800
251 Salbutamol Tab 2 mg Tablet - - - - - - - - - - -
252 Salbutamol Tab 4 mg - - - 60 - (60) - 81 - 4,860 - 63,504
253 Sefadroxil syrup 125mg/ml Botol - - - - - - - 4,581 - - - -
254 Sefadroxil Kapsul 250 mg Kapsul - - - - - - - - - - -
255 Sefadroxil Kapsul 500 mg Kapsul - - - 246 - (246) - 587 - 144,402 - 48,721
256 Setirizine Tab 10 mg Tablet - - - - - - - 103 - - - -
257 Setirizine Suspensi Botol - - - - - - - 3,192 - - - -
258 Semen Seng Fosfat Serbuk dan Cairan Botol - - - - - - - - - - -
259 Sianokobalamin (Vit B12 ) Inj 500 mcg / ml-1ml vial - - - - - - - 1,335 - - - -
260 Sianokobalamin ( Vit B12 ) Tab 50 mg Tablet - - - 30 - (30) - 53 - 1,590 - 195,570
261 Seftriakson Inj 1 g/Vial vial - - - - - - - 5,143 - - - -
262 Sefotaxim Inj 1 g/ Vial vial - - - - - - - 7,700 - - - -
263 Simetidin Tab 200 mg Tablet - - - - - - - - - - -
264 Simvastatin 5 mg Tablet - - - - - - - - - - -
265 Simvastatin Tab 10 mg Tablet - - - 10 - (10) - 110 - 1,100 - 24,860
266 Siprofloxasin Tab 250 mg Tablet - - - - - - - - - - -
267 Siprofloxasin Tab 500 mg Tablet - - - 20 - (20) - 305 - 6,100 - 298,900
268 Scabimite Krim Tube - - - - - - - 37,525 - - - -
269 Sofratule (Daryantull) Pcs - - - - - - - - - - -
270 Sohobion Injeksi Ampul - - - 10 - (10) - 4,740 - 47,400 - 94,800
271 Silk Benang Bedah Sutera + Jarum No.2/0 75 cm Pcs - - - - - - - 4,583 - - - -
272 Silk Benang Bedah Sutera + Jarum No.3/0 75 cm pcs - - - - - - - 4,583 - - - -
273 Sofband Gips 6 Inch roll - - - - - - - 37,500 - - - -
274 Sofband Gips 4 inch Roll - - - - - - - 28,500 - - - -
275 Stik Glukosa Easy Touch Buah - - - - - - - - - - -
276 Stik As. Urat Easy Touch Buah - - - - - - - - - - -
277 Stik Kolesterol Easy Touch Buah - - - - - - - - - - -
278 Tetrasiklin Kapsul 250 mg Kapsul - - - - - - - 193 - - - -
279 Tetrasiklin Kapsul 500 mg Kapsul - - - - - - - 348 - - - -

LPLPO/KAB MBD Page 29


1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
280 Terramycin Injeksi Vial - - - - - - - 15,300 - - - -
281 Thiamin HCL / Monoitrat (Vit B1) Tab 50 mg Tablet - - - 322 - (322) - 98 - 31,556 - 323,400
282 Thiamin HCL ( Vit B1 ) Inj 100 mg/ml-1ml Vial - - - - - - - - - - -
283 Tranfusi Set (Blood Set) Pcs - - - - - - - 3,600 - - - -
284 Tramadol injeksi Ampul - - - - - - - - - - -
285 Urine Bag pcs - - - - - - - 3,000 - - - 30,000
286 Ultra Sonic Gell Botol - - - - - - - 12,854 - - - -
287 Under Pad 60 cm x 90 Steril With SAP Pcs - - - - - - - - - - -
288 Ventolin injeksi (inhaler) Vial - - - - - - - - - - -
289 Ventolin Nebulizer Ampul - - - - - - - 28,220 - - - -
290 Vaksin Verorab (Anti Rabies) vial - - - - - - - 267,000 - - - -
291 Vitamin B Complex Tab Tablet - - - 652 - (652) - 147 - 95,844 - 116,130
292 Vitamin B Complex Inj Ampul - - - - - - - 11,273 - - - 112,730
293 Wing Needlee No. 23 pcs - - - - - - - 14,000 - - - -
294 Wing Needlee No. 25 Pcs - - - - - - - 14,000 - - - -
295 Wing Needlee No. 27 Pcs - - - - - - - 14,000 - - - -
296 Yodium Povidon Larutan 10% - 60 ml Botol - - - 1 - (1) - 7,532 - 7,532 - 67,788
297 Yodium Povidon Larutan 10% - 300 ml Botol - - - - - - - - - - -
298 Yodium Povidon Larutan 10% - 1000 ml Botol - - - 1 - (1) - 79,650 - 79,650 - 637,200
299 Zinc Tablet dispersible 20 mg Tablet - - - 3 - (3) - 658 - 1,974 - 3,222,226
TOTAL HARGA - 2,094,406 108,550 40,639,536

UMUM
JUMLAH KUNJUNGAN RESEP ASKES JUMLAH
BAYAR TIDAK BAYAR
0 0 …………………………………………. 2019

Mengetahui/Menyetujui; Yang Menyerahkan; Yang Meminta; Yang Menerima;


Kepala Dinas Kesehatan Kabupaten Petugas Gudang Farmasi, Pimpinan Puskesmas, Petugas Puskesmas,
Maluku Barat Daya,

NIP. NIP. NIP. NIP.

LPLPO/KAB MBD Page 30


RENCANA KEBUTUHAN OBAT PUSKESMAS MARSELA TAH

KODE/NO.
NAMA OBAT dan PERBEKALAN KESEHATAN
URT
a b
1 Alat Suntik Sekali Pakai 1 CC
2 Alat Suntik Sekali Pakai 2,5 CC
3 Alat Suntik Sekali Pakai 3 CC
4 Alat Suntik Sekali Pakai 5 CC
5 Alat Suntik Sekali Pakai 10 CC
6 Alat Suntik Sekali Pakai 20 CC
7 Abocath ( I.V. Catheter) No. 18
8 Abocath (I.V.Catheter) No.20
9 Abocath (I.V.Catheter) No.22
10 Abocath (I.V.Catheter) No.24
11 Abocath (I.V.Catheter) No.26
12 Albendasol Tab 400 mg
13 Alkohol 70 % 1000 ml ( Etanol )
14 Alkohol 70 % 100 ml ( Etanol )
15 Allopurinol Tab 100 mg
16 Allopurinol Tab 300 mg
17 Ambroxol sirup 15 mg/ml
18 Ambroxol Tab 30 mg
19 Aminofillin inj 24 mg/ml-10 ml
20 Aminofilin Tab 200 mg
21 Amoxicillin Kaplet 250 mg
22 Amoxicillin Kapsul 500 mg
23 Amoxicillin Sirup Kering 125 mg/ 5 ml
24 Ampisillin Kaplet 250 mg
25 Ampisillin Kaplet 500 mg
26 Ampisillin Serbuk Inj 1.m/ i.v 1000 mg/ml
27 Ampisillin sirup Kering 125 mg/ 5 ml
28 Amlodipin 5 tablet
29 Amlodipin 10 mg
30 Anvomer B6 Tab
31 Antasida Doen Tab Kombinasi
32 Antasida Doen II Suspensi
33 Anti Fungi Doen Kombinasi (Asam Bensoat 3%+As.Salisilat 6% (Whitefield)
34 Anti Malaria Doen Kombinasi (DHP)
35 Aquadest Steril (Air Untuk Injeksi Ampul 25 ml)
36 Artemeter injeksi 80 mg/ml
37 Artesunat Injeksi
38 Asam Salisilat 2% + Belerang Endap 4% ( salf 2-4 )
39 Asam Askorbat ( Vit C ) Tab 50 mg
40 Asam Folat Tab 1 mg
41 Asam Mefenamat Kapsul 250 mg
42 Asam Mefenamat Kaplet 500 mg
43 Asam Traneksamat injeksi 100 mg/ml
44 Aspar - K Tab
45 Atropina Sulfat Inj 0,25 mg/ml-1ml
46 ATS Injeksi 1500 IU
47 Asiklovir Krim 5 %
48 Asiklovir Tab 200 mg
49 Asiklovir Tab 400 mg
50 Bedak Salysil Serbuk 2 %
51 Benzatin Bensil Penisillin 1,2 Juta IU
52 Bessi II Sulfat Tab Kombinasi : Besi II sulfat 7H2O 200 mg, Asam Folat 0,25 mg (Fe = Tambah Darah)
53 Betametason 0,1% Krim
54 Bisoprolol tab
55 Bioplasenton gel
56 Buscopan Injeksi
57 Bufacetin Salep Kulit Krim
58 Captopril Tablet 12,5 mg
59 Captopril Tablet 25 mg
60 Catgut Chromic + Jarum No. 2/0 75 cm
61 Catgut Chromic + Jarum No. 3/0 75 cm
62 Catgut Plain + Jarum No.2/0 75 cm
63 Catgut Plain + Jarum No. 3/0 75 cm
64 Catapres Injeksi
65 Chloramfeniramine Maleat (Ctm)
66 Chloramfenikol Kapsul 250 mg
67 Chloramfenikol Kapsul 500 mg
68 Chloramfenikol Salf Mata 1%
69 Chloramfenikol Suspensi 125 mg/5 ml
70 Chloramfenikol Tetes Telinga 3 %
71 Chloramfenikol Salep Kulit 2 %
72 Clindamiciyn 150 mg
73 Clindamicin 300 mg
74 Cotrimoxasol Suspensi
75 Cotrimoxasol Tab kombinasi : Sulfametoksazole 400mg , Trimetroprim 80 mg
76 Dexamethason Inj 5 mg/ml-1 ml
77 Dexamethason Tab 0,5 mg
78 Diazepam Inj 5mg/ml-2ml
79 Diazepam Tab 2 mg
80 Diazepam Tab 5 mg
81 Difenhidramin HCL Inj 10 mg/ml-1 ml
82 Digoxin Tab 0,25 mg
83 Dimenhidrinat Tablet 50 mg
84 Doksisiklik Kapsul 100 mg
85 Domperidon Tab 10 mg
86 Dulcolax Tab
87 Dulcolax Suppos
88 Diltiasem HCL Tab 30 mg
89 Efedrin HCL ( Efedrina ) Tab 25 mg
90 Elastic Verband 4 Inchi
91 Elastic Verband 6 Inchi
92 Erlamycetin Tetes Telinga
93 Epinefrin HCL / Bitartrat ( Adrenalin ) Inj. 0,1%-1ml
94 ErLamycetin Tetes Mata
95 Eritr0misin Kapsul 250 mg
96 Eritromisin Kapsul 500 mg
97 Eritromisin Sirup 200 mg/5 ml
98 Etil Klorida Spray
99 Etambutol HCL ( Etambutol ) Tab 250 mg
100 Extension Tube
101 Eugenol cairan
102 Fenobarbital Inj 50 mg/ml-2ml
103 Fenobarbital Tab 30 mg
104 Fenol Gliseron tetes telinga 10 %
105 Fitomenadion ( Vit K1 ) Inj 10 mg/ml-1ml
106 Fitomenadion ( Vit K1 ) Tab Salut 10 mg
107 Foley Catheter T. 6
108 Foley Catheter T. 8
109 Foley Catheter T.10
110 Foley Catheter T.12
111 Foley Catheter T.14
112 Foley Catheter T. 16
113 Foley Catheter T.18
114 Foley Catheter T. 20
115 Foley Catheter T. 22
116 Foley Catheter T. 24
117 Flagystatin Tablet Vagina
118 Furosemida Inj i.v i.m 10 mg/ml
119 Furosemida Tab 40 mg
120 Formalin Cairan
121 Gentamisin Inj 80 mg/ 2ml
122 Gentamisin Salf Kulit 0,1 %
123 Gentamisin Slufat Tetes Mata 0,3 %
124 Glimepride Tab 4 mg
125 Gentian Violet Larutan 1 %
126 Gipsonal Gipsum 4 Inchi
127 Gipsonal Gipsum 6 Inchi
128 Glibenclamide Tab
129 Gliseril Guaiakolat Tab 100 mg/ Guafenisine
130 Glukosa Larutan Infus 5 % Steril
131 Glukosa Larutan Infus 10 % Steril
132 Glukosa Larutan Infus 40 % Steril
133 Griseovulvin Tab 125 mg, Micronized
134 Handscoen S
135 Handscoen M
136 Handscoen L
137 Handscoen No. 6
138 Handscoen No.7
139 Handscoen No.7,5
140 Hidroklorotiasida ( HCT ) Tab 25 mg
141 Hidrokortison Krim 2,5 mg
142 Ibuprofen Suspensi
143 Ibuprofen Tab 200 mg
144 Ibuprofen Tab 400 mg
145 Infusion Set Anak
146 Infusion Set Dewasa
147 Isoniasid ( INH ) Tab 100 mg
148 Isoniasid ( INH ) Tab 300 mg
149 Isosorbid Dinitrat Tab Sublingual 5 mg
150 Kalium Glukonat injeksi 10% (100mg/ml)
151 Kalsium Laktat ( Kalk ) Tab 500 mg
152 Karbamasepin Tab 200 mg
153 KAEN-3B Larutan infus (mengandung NaCl 1,75+KCL
1,5gr+ Na Lactat 2,24 gr, Dextrose 27 gr)
154 Kapas Putih 1000 gr (Kapas Putih 1 Kg)
155 Kantung Darah 250 cc
156 Kapas Pembalut Absorben 250 Gram
157 Kapas Berlemak 500 mg
158 Kasa Roll Panjang Besar 40x80 Cm
159 Kasa Kompres 40/40 Steril
160 Kasa Pembalut Hidrofil Steril 16 cm x 16 cm
161 Kasa Pembalut Hidrofil Supergrade 40 cm x 16 cm
162 Kasa Steril 10 cm x 10 cm
163 Keterolac Inj 30 mg
164 Ketokonazole Tab 200 mg
165 Ketokonazole Krim
166 Kinina Dihidroklorida ( Kina ) Inj 25 %-2ml
167 Kuinin Sulfat Tab 222 mg ( H2O ) (Qunine 222 mg)
168 Klorpromasin HCL Tab Salut 25 mg
169 Klorpromasin HCL Tab Salut 100 mg
170 Klorpromasin Inj 25 mg/ml-1ml
171 Klorpromasin Inj 5 mg/ ml-2ml
172 Kodein HCL ( Kodeina ) Tab 10 mg
173 Klip Plastik 7 x 10 cm
174 Klip Plastik 8 x 5 cm
175 Kertas pulvis
176 Lancet blood
177 Lidokain Com, Inj Kombinasi
178 Levofloksasin 500 mg
179 Loratadine Tablet 10 mg
180 Loperamide 10 mg
181 Maxiflow Baby (Masker Oksigen)
182 Maxiflow Anak (Masker Oksigen)
183 Maxiflow Dewasa (Masker Oksigen)
184 Masker
185 Masker Respirator N-95
186 Methilprednisolon Tablet 4 mg
187 Methilergometrin Maleat Inj 0,200 mg/ml-1ml
188 Methilergometrin Maleat Tab salut 0,125 mg
189 Meloxicam 7,5 mg
190 Meloxicam 15 mg
191 Metformin HCL Tab 500 mg
192 Metformin HCL Tab 850 mg
193 Metoklopramide Tab 10 mg
194 Metronidasol Infus 500 mg/100 ml
195 Metronidasol Tab 250 mg
196 Metronidasol Tab 500 mg
197 Mikonazol Krim / Salf 2% ( Nitrat )
198 Microlax Suppos
199 Mucus Extractor
200 Natrium Diklofenak Tab 25 mg
201 Natrium Diklofenak Tab 50 mg
202 Natrium Klorida Larutan Infus 0,9% Steril
203 Nifedipin Tab 10 mg
204 Nistatin 100.000 IU/g Tab Vaginal
205 Nistatin 500.000 IU/ Tab Salut
206 NGT No. 6
207 NGT.No. 8
208 NGT.No.12
209 NGT.No.14
210 NGT.No.18
211 Obat Batuk Hitam
212 Omeprasol Tab 20 mg
213 Ondansetron Tablet 4 mg
214 Obgyn Steril Handscoen
215 Oralit/ Garam Oralit
216 Objec Glass/Slide
217 Oxibiotic injeksi
218 Oxitetrasikllin HCL Inj I.M 50mg/ml-10ml
219 Oxitetrasikllin HCL Salep Kulit 3%
220 Oxitetrasikllin Salep Mata 1%
221 Oxitosin Inj 10 IU /ml-1ml (pitogin Injeksi)
222 Oxyflow Baby
223 Oxyflow Anak
224 Oxyflow Dewasa
225 Pap Smer Kit S
226 Pap Smer Kit M
227 Pap Smer Kit L
228 Papaverin Inj 40mg/ml
229 Papaverin Tab 40 mg
230 Parasetamol Sirup 120 mg/ml
231 Parasetamol Tab 500 mg
232 Pirantel Pamoat ( Pirantel ) Tab 125 mg
233 Piridoksin HCL ( Vit B6 ) Tab 10 mg
234 Piroxicam Tab 10 mg
235 Piroxicam Tab 20 mg
236 Plester 5 Yard x 2 Inch
237 Pirasetam Tab 400 mg
238 Pirasinamida Tab 500 mg
239 Prednison Tab 5 mg
240 Primakuin Tab 15 mg
241 Primperan Injeksi
242 Prokain Penisillin G Inj 3 Juta IU
243 Propanolol HCL ( Propanolol ) Tab 40 mg
244 Ranitidin Inj 25 mg/ml
245 Ranitidin Tab 150 mg
246 Retinol ( Vit A ) Kapsul Lunak 100.000 IU
247 Retinol ( Vit A ) Kapsul Lunak 200.000 IU
248 Retinol ( Vit A ) Kapsul Lunak 50.000 IU
249 Ringer Laktat Larutan Infus Steril
250 Rivanol Larutan (Etakridin ) 300 ml
251 Salbutamol Tab 2 mg
252 Salbutamol Tab 4 mg
253 Sefadroxil syrup 125mg/ml
254 Sefadroxil Kapsul 250 mg
255 Sefadroxil Kapsul 500 mg
256 Setirizine Tab 10 mg
257 Setirizine Suspensi
258 Semen Seng Fosfat Serbuk dan Cairan
259 Sianokobalamin (Vit B12 ) Inj 500 mcg / ml-1ml
260 Sianokobalamin ( Vit B12 ) Tab 50 mg
261 Seftriakson Inj 1 g/Vial
262 Sefotaxim Inj 1 g/ Vial
263 Simetidin Tab 200 mg
264 Simvastatin 5 mg
265 Simvastatin Tab 10 mg
266 Siprofloxasin Tab 250 mg
267 Siprofloxasin Tab 500 mg
268 Scabimite Krim
269 Sofratule (Daryantull)
270 Sohobion Injeksi
271 Silk Benang Bedah Sutera + Jarum No.2/0 75 cm
272 Silk Benang Bedah Sutera + Jarum No.3/0 75 cm
273 Sofband Gips 6 Inch
274 Sofband Gips 4 inch
275 Stik Glukosa Easy Touch
276 Stik As. Urat Easy Touch
277 Stik Kolesterol Easy Touch
278 Tetrasiklin Kapsul 250 mg
279 Tetrasiklin Kapsul 500 mg
280 Terramycin Injeksi
281 Thiamin HCL / Monoitrat (Vit B1) Tab 50 mg
282 Thiamin HCL ( Vit B1 ) Inj 100 mg/ml-1ml
283 Tranfusi Set (Blood Set)
284 Tramadol injeksi
285 Urine Bag
286 Ultra Sonic Gell
287 Under Pad 60 cm x 90 Steril With SAP
288 Ventolin injeksi (inhaler)
289 Ventolin Nebulizer
290 Vaksin Verorab (Anti Rabies)
291 Vitamin B Complex Tab
292 Vitamin B Complex Inj
293 Wing Needlee No. 23
294 Wing Needlee No. 25
295 Wing Needlee No. 27
296 Yodium Povidon Larutan 10% - 60 ml
297 Yodium Povidon Larutan 10% - 300 ml
298 Yodium Povidon Larutan 10% - 1000 ml
299 Zinc Tablet dispersible 20 mg
TOTAL HARGA

Mengetahui
Pimpinan Puskesmas Marsela

ROBERTH DJERSON LEWIER


NIP. 19740711 199703 1004
AS MARSELA TAHUN 2020
AN RATA-
RENCANA Harga
RATA PER JUMLAH
SATUAN KEBUTUH Satuan
BULAN HARGA (Rp)
AN 2020 (Rp)
SELAMA
c d e f g
Buah 50 900 1,100 990,000
Buah 50 900 1,750 1,575,000
Buah 50 900 779 701,100
Buah 25 450 968 435,600
Buah - - 1,375 -
Buah - - 1,500 -
Buah 5 90 3,800 342,000
Buah 20 360 3,800 1,368,000
Buah 20 360 3,800 1,368,000
Buah 5 90 3,800 342,000
Buah 5 90 4,100 369,000
Tablet - - 492 -
Botol 3 54 25,000 1,350,000
Botol - - -
Tablet 50 900 -
Tablet 50 900 108 97,200
Botol 50 900 6,095 5,485,500
Tablet 1,000 18,000 201 3,618,000
Ampul - - 3,280 -
Tablet 10 180 107 19,260
Kaplet 1,000 18,000 212 3,816,000
Kapsul 500 9,000 245 2,205,000
Botol 50 900 2,790 2,511,000
Kaplet 200 3,600 -
Kaplet 200 3,600 450 1,620,000
Vial - - 10,296 -
Botol - - -
tablet 100 1,800 99 178,200
Tablet 300 5,400 83 448,200
Tablet 1,000 18,000 3,987 71,766,000
Tablet 200 3,600 58 208,800
Botol 50 900 2,257 2,031,300
Tube 10 180 5,620 1,011,600
Tablet 25 450 2,070 931,500
Ampul 10 180 2,798 503,640
Ampul - - 26,600 -
Ampul 5 90 48,750 4,387,500
Tube 15 270 3,274 883,980
Tablet 1,500 27,000 131 3,537,000
Tablet 200 3,600 88 316,800
Kaplet - - -
Kaplet 500 9,000 195 1,755,000
Ampul 50 900 2,798 2,518,200
Tablet - - 4,312 -
Ampul 5 90 1,914 172,260
Ampul 5 90 43,183 3,886,470
Tube 25 450 4,383 1,972,350
Tablet - - 236 -
Tablet 100 1,800 414 745,200
Dus 20 360 1,142 411,120
Vial - - -
Tablet 1,000 18,000 445 8,010,000
Tube 20 360 1,520 547,200
Tablet 30 540 -
Tube 15 270 17,928 4,840,560
Ampul - - -
Tube 10 180 4,024 724,320
Tablet 200 3,600 87 313,200
Tablet - - 86 -
Pcs 15 270 5,583 1,507,410
Pcs 15 270 5,583 1,507,410
Pcs 25 450 5,583 2,512,350
Pcs 15 270 5,583 1,507,410
Ampul - - 97,220 -
Tablet 1,500 27,000 26 702,000
Kapsul 150 2,700 357 963,900
Kapsul 150 2,700 -
Tube 20 360 2,160 777,600
Botol 10 180 -
Botol 50 900 2,590 2,331,000
Tube 25 450 4,042 1,818,900
Kapsul 50 900 720 648,000
Kapsul 50 900 893 803,700
Botol 500 9,000 2,155 19,395,000
Tablet 1,000 18,000 132 2,376,000
Vial 25 450 1,378 620,100
Tablet 250 4,500 37 166,500
Ampul 5 90 2,150 193,500
Tablet - - 86 -
Tablet 100 1,800 115 207,000
Vial 25 450 1,373 617,850
Tablet - - 104 -
Tablet 50 900 -
Kapsul - - 264 -
Tablet 100 1,800 190 342,000
Tablet 50 900 166 149,400
Suppos 10 180 36,200 6,516,000
Tablet - - 153 -
Tablet 25 450 -
Buah 25 450 30,250 13,612,500
Buah 25 450 -
Botol 100 1,800 5,658 10,184,400
Ampul 25 450 2,486 1,118,700
Botol 25 450 8,183 3,682,350
Kapsul 100 1,800 693 1,247,400
Kapsul 100 1,800 704 1,267,200
Botol 50 900 6,788 6,109,200
Botol - - -
Tablet - - -
Pcs - - -
Botol - - 20,000 -
vial - - 2,325 -
Tablet 25 450 243 109,350
Botol 25 450 2,590 1,165,500
Vial 10 180 4,438 798,840
Tablet 50 900 890 801,000
Botol 5 90 30,000 2,700,000
Buah 5 90 30,000 2,700,000
Buah 5 90 30,000 2,700,000
Buah 5 90 8,000 720,000
Buah 5 90 8,000 720,000
Buah 5 90 8,000 720,000
Buah 5 90 8,000 720,000
Buah 5 90 8,000 720,000
Buah 5 90 8,000 720,000
Buah 5 90 8,000 720,000
Tablet 10 180 29,520 5,313,600
Vial 10 180 1,850 333,000
Tablet 100 1,800 88 158,400
Botol 10 180 -
Ampul - - 3,854 -
Tube 25 450 -
Botol 10 180 5,020 903,600
Tablet 50 900 273 245,700
Botol 25 450 5,200 2,340,000
Buah 10 180 28,500 5,130,000
Buah 10 180 37,500 6,750,000
Tablet 100 1,800 720 1,296,000
Tablet 2,500 45,000 132 5,940,000
Botol 10 180 6,900 1,242,000
Botol 10 180 6,840 1,231,200
Botol 10 180 -
Tablet 50 900 242 217,800
Pcs 100 1,800 -
Pcs 100 1,800 -
Pcs 100 1,800 -
Pcs 100 1,800 -
Pcs 100 1,800 6,985 12,573,000
Pcs 100 1,800 6,985 12,573,000
Tablet - - 194 -
Tube 50 900 2,846 2,561,400
Botol 50 900 5,739 5,165,100
Tablet 50 900 -
Tablet 1,000 18,000 -
Pcs 25 450 3,500 1,575,000
Pcs 25 450 3,200 1,440,000
Tablet - - -
Tablet - - 165 -
Tablet 25 450 -
Ampul - - 7,800 -
Tablet 1,000 18,000 62 1,116,000
Tablet - - 241 -
Botol 25 450 23,500 10,575,000
Roll 2 36 -
Roll - - -
Roll 10 180 22,000 3,960,000
Buah 10 180 16,500 2,970,000
Buah 1 18 105,000 1,890,000
Buah 100 1,800 1,600 2,880,000
Buah 10 180 8,000 1,440,000
Buah 10 180 36,960 6,652,800
Buah 10 180 -
Ampul 10 180 1,265 227,700
Tablet 100 1,800 311 559,800
Tube 50 900 2,893 2,603,700
Ampul - - 7,440 -
Tablet - - 799 -
Tablet - - -
Tablet - - 179 -
Ampul - - 1,550 -
Ampul - - -
Tablet - - 600 -
Pak 10 180 -
Pak 10 180 -
Pak 20 360 -
Buah 100 1,800 623 1,121,400
Ampul 100 1,800 1,433 2,579,400
Tablet 100 1,800 520 936,000
Tablet 100 1,800 185 333,000
Tablet 100 1,800 -
Pcs - - -
Pcs - - -
Pcs - - -
Botol 1,000 18,000 1,226 22,068,000
Buah 20 360 -
Tablet 200 3,600 -
Tablet - - 9,900 -
Tablet 100 1,800 185 333,000
Tablet 100 1,800 -
Tablet 100 1,800 1,719 3,094,200
Tablet 200 3,600 138 496,800
Tablet 200 3,600 168 604,800
Tablet 100 1,800 117 210,600
Botol 5 90 11,547 1,039,230
Tablet 100 1,800 99 178,200
Tablet 100 1,800 176 316,800
Tube 25 450 4,268 1,920,600
Suppos 50 900 -
Buah 25 450 -
Tablet 500 9,000 163 1,467,000
Tablet 500 9,000 162 1,458,000
Botol 15 270 6,410 1,730,700
Tablet 100 1,800 219 394,200
Tablet 25 450 858 386,100
Tablet - - 768 -
Buah 5 90 22,000 1,980,000
Buah 5 90 22,000 1,980,000
Buah 5 90 22,000 1,980,000
Buah 5 90 22,000 1,980,000
Buah 5 90 22,000 1,980,000
Botol 75 1,350 2,670 3,604,500
Tablet 150 2,700 150 405,000
Tablet 50 900 1,090 981,000
Pcs 50 900 1,500 1,350,000
Saschet 250 4,500 296 1,332,000
Pcs 200 3,600 -
Vial 50 900 -
Vial 25 450 -
Tube 100 1,800 1,259 2,266,200
Tube 100 1,800 2,600 4,680,000
Ampul 100 1,800 3,020 5,436,000
Pcs - - -
Pcs - - -
Pcs - - -
Pcs - - -
Pcs - -
Pcs - -
Ampul - - -
Tablet 50 900 -
Botol 100 1,800 1,252 2,253,600
Tablet 3,000 54,000 66 3,564,000
Tablet 500 9,000 334 3,006,000
Tablet 2,000 36,000 154 5,544,000
Tablet 500 9,000 334 3,006,000
Tablet 500 9,000 244 2,196,000
Buah 50 900 -
Tablet - - -
Tablet - - -
Tablet 1,000 18,000 91 1,638,000
Tablet 100 1,800 175 315,000
Vial - - -
Ampul - - 22,880 -
Tablet 50 900 64 57,600
Vial 100 1,800 1,540 2,772,000
Tablet 500 9,000 121 1,089,000
Kapsul 200 3,600 355 1,278,000
Kapsul 200 3,600 648 2,332,800
Kapsul - - -
Botol 25 450 7,150 3,217,500
Botol 25 450 7,200 3,240,000
Tablet 100 1,800 -
100 1,800 81 145,800
Botol 100 1,800 4,581 8,245,800
Kapsul 500 9,000 -
Kapsul 2,000 36,000 587 21,132,000
Tablet 500 9,000 103 927,000
Botol 50 900 3,192 2,872,800
Botol - - -
vial 100 1,800 1,335 2,403,000
Tablet 2,000 36,000 53 1,908,000
vial - - 5,143 -
vial - - 7,700 -
Tablet - - -
Tablet 1,000 18,000 -
Tablet 1,000 18,000 110 1,980,000
Tablet 1,000 18,000 -
Tablet 1,000 18,000 305 5,490,000
Tube 25 450 37,525 16,886,250
Pcs - - -
Ampul 100 1,800 4,740 8,532,000
Pcs - - 4,583 -
pcs - - 4,583 -
roll - - 37,500 -
Roll - - 28,500 -
Buah 500 9,000 -
Buah 500 9,000 -
Buah 500 9,000 -
Kapsul 1,000 18,000 193 3,474,000
Kapsul 1,000 18,000 348 6,264,000
Vial - - 15,300 -
Tablet 2,000 36,000 98 3,528,000
Vial - - -
Pcs - - 3,600 -
Ampul 10 180 -
pcs 10 180 3,000 540,000
Botol - 12,854 -
Pcs 10 180 -
Vial - - -
Ampul - - 28,220 -
vial - - 267,000 -
Tablet 3,000 54,000 147 7,938,000
Ampul 100 1,800 11,273 20,291,400
pcs 100 1,800 14,000 25,200,000
Pcs 100 1,800 14,000 25,200,000
Pcs 100 1,800 14,000 25,200,000
Botol 100 1,800 7,532 13,557,600
Botol - - -
Botol 10 180 79,650 14,337,000
Tablet 200 3,600 658 2,368,800
665,630,010

MARSELA,21 JANUARI 2020


Petugas Puskesmas,

AGUNG PRATOYO, S.Farm., Apt


NRPK . 25.6.0504262
RENCANA KEBUTUHAN OBAT PUSKESMAS MARSELA TAH

KODE/NO.
NAMA OBAT dan PERBEKALAN KESEHATAN
URT
a b
1 Alat Suntik Sekali Pakai 1 CC
2 Alat Suntik Sekali Pakai 2,5 CC
3 Alat Suntik Sekali Pakai 3 CC
4 Alat Suntik Sekali Pakai 5 CC
5 Alat Suntik Sekali Pakai 10 CC
6 Alat Suntik Sekali Pakai 20 CC
7 Abocath ( I.V. Catheter) No. 18
8 Abocath (I.V.Catheter) No.20
9 Abocath (I.V.Catheter) No.22
10 Abocath (I.V.Catheter) No.24
11 Abocath (I.V.Catheter) No.26
12 Albendasol Tab 400 mg
13 Alkohol 70 % 1000 ml ( Etanol )
14 Alkohol 70 % 100 ml ( Etanol )
15 Allopurinol Tab 100 mg
16 Allopurinol Tab 300 mg
17 Ambroxol sirup 15 mg/ml
18 Ambroxol Tab 30 mg
19 Aminofillin inj 24 mg/ml-10 ml
20 Aminofilin Tab 200 mg
21 Amoxicillin Kaplet 250 mg
22 Amoxicillin Kapsul 500 mg
23 Amoxicillin Sirup Kering 125 mg/ 5 ml
24 Ampisillin Kaplet 250 mg
25 Ampisillin Kaplet 500 mg
26 Ampisillin Serbuk Inj 1.m/ i.v 1000 mg/ml
27 Ampisillin sirup Kering 125 mg/ 5 ml
28 Amlodipin 5 tablet
29 Amlodipin 10 mg
30 Anvomer B6 Tab
31 Antasida Doen Tab Kombinasi
32 Antasida Doen II Suspensi
33 Anti Fungi Doen Kombinasi (Asam Bensoat 3%+As.Salisilat 6% (Whitefield)
34 Anti Malaria Doen Kombinasi (DHP)
35 Aquadest Steril (Air Untuk Injeksi Ampul 25 ml)
36 Artemeter injeksi 80 mg/ml
37 Artesunat Injeksi
38 Asam Salisilat 2% + Belerang Endap 4% ( salf 2-4 )
39 Asam Askorbat ( Vit C ) Tab 50 mg
40 Asam Folat Tab 1 mg
41 Asam Mefenamat Kapsul 250 mg
42 Asam Mefenamat Kaplet 500 mg
43 Asam Traneksamat injeksi 100 mg/ml
44 Aspar - K Tab
45 Atropina Sulfat Inj 0,25 mg/ml-1ml
46 ATS Injeksi 1500 IU
47 Asiklovir Krim 5 %
48 Asiklovir Tab 200 mg
49 Asiklovir Tab 400 mg
50 Bedak Salysil Serbuk 2 %
51 Benzatin Bensil Penisillin 1,2 Juta IU
52 Bessi II Sulfat Tab Kombinasi : Besi II sulfat 7H2O 200 mg, Asam Folat 0,25 mg (Fe = Tambah Darah)
53 Betametason 0,1% Krim
54 Bisoprolol tab
55 Bioplasenton gel
56 Buscopan Injeksi
57 Bufacetin Salep Kulit Krim
58 Captopril Tablet 12,5 mg
59 Captopril Tablet 25 mg
60 Catgut Chromic + Jarum No. 2/0 75 cm
61 Catgut Chromic + Jarum No. 3/0 75 cm
62 Catgut Plain + Jarum No.2/0 75 cm
63 Catgut Plain + Jarum No. 3/0 75 cm
64 Catapres Injeksi
65 Chloramfeniramine Maleat (Ctm)
66 Chloramfenikol Kapsul 250 mg
67 Chloramfenikol Kapsul 500 mg
68 Chloramfenikol Salf Mata 1%
69 Chloramfenikol Suspensi 125 mg/5 ml
70 Chloramfenikol Tetes Telinga 3 %
71 Chloramfenikol Salep Kulit 2 %
72 Clindamiciyn 150 mg
73 Clindamicin 300 mg
74 Cotrimoxasol Suspensi
75 Cotrimoxasol Tab kombinasi : Sulfametoksazole 400mg , Trimetroprim 80 mg
76 Dexamethason Inj 5 mg/ml-1 ml
77 Dexamethason Tab 0,5 mg
78 Diazepam Inj 5mg/ml-2ml
79 Diazepam Tab 2 mg
80 Diazepam Tab 5 mg
81 Difenhidramin HCL Inj 10 mg/ml-1 ml
82 Digoxin Tab 0,25 mg
83 Dimenhidrinat Tablet 50 mg
84 Doksisiklik Kapsul 100 mg
85 Domperidon Tab 10 mg
86 Dulcolax Tab
87 Dulcolax Suppos
88 Diltiasem HCL Tab 30 mg
89 Efedrin HCL ( Efedrina ) Tab 25 mg
90 Elastic Verband 4 Inchi
91 Elastic Verband 6 Inchi
92 Erlamycetin Tetes Telinga
93 Epinefrin HCL / Bitartrat ( Adrenalin ) Inj. 0,1%-1ml
94 ErLamycetin Tetes Mata
95 Eritr0misin Kapsul 250 mg
96 Eritromisin Kapsul 500 mg
97 Eritromisin Sirup 200 mg/5 ml
98 Etil Klorida Spray
99 Etambutol HCL ( Etambutol ) Tab 250 mg
100 Extension Tube
101 Eugenol cairan
102 Fenobarbital Inj 50 mg/ml-2ml
103 Fenobarbital Tab 30 mg
104 Fenol Gliseron tetes telinga 10 %
105 Fitomenadion ( Vit K1 ) Inj 10 mg/ml-1ml
106 Fitomenadion ( Vit K1 ) Tab Salut 10 mg
107 Foley Catheter T. 6
108 Foley Catheter T. 8
109 Foley Catheter T.10
110 Foley Catheter T.12
111 Foley Catheter T.14
112 Foley Catheter T. 16
113 Foley Catheter T.18
114 Foley Catheter T. 20
115 Foley Catheter T. 22
116 Foley Catheter T. 24
117 Flagystatin Tablet Vagina
118 Furosemida Inj i.v i.m 10 mg/ml
119 Furosemida Tab 40 mg
120 Formalin Cairan
121 Gentamisin Inj 80 mg/ 2ml
122 Gentamisin Salf Kulit 0,1 %
123 Gentamisin Slufat Tetes Mata 0,3 %
124 Glimepride Tab 4 mg
125 Gentian Violet Larutan 1 %
126 Gipsonal Gipsum 4 Inchi
127 Gipsonal Gipsum 6 Inchi
128 Glibenclamide Tab
129 Gliseril Guaiakolat Tab 100 mg/ Guafenisine
130 Glukosa Larutan Infus 5 % Steril
131 Glukosa Larutan Infus 10 % Steril
132 Glukosa Larutan Infus 40 % Steril
133 Griseovulvin Tab 125 mg, Micronized
134 Handscoen S
135 Handscoen M
136 Handscoen L
137 Handscoen No. 6
138 Handscoen No.7
139 Handscoen No.7,5
140 Hidroklorotiasida ( HCT ) Tab 25 mg
141 Hidrokortison Krim 2,5 mg
142 Ibuprofen Suspensi
143 Ibuprofen Tab 200 mg
144 Ibuprofen Tab 400 mg
145 Infusion Set Anak
146 Infusion Set Dewasa
147 Isoniasid ( INH ) Tab 100 mg
148 Isoniasid ( INH ) Tab 300 mg
149 Isosorbid Dinitrat Tab Sublingual 5 mg
150 Kalium Glukonat injeksi 10% (100mg/ml)
151 Kalsium Laktat ( Kalk ) Tab 500 mg
152 Karbamasepin Tab 200 mg
153 KAEN-3B Larutan infus (mengandung NaCl 1,75+KCL
1,5gr+ Na Lactat 2,24 gr, Dextrose 27 gr)
154 Kapas Putih 1000 gr (Kapas Putih 1 Kg)
155 Kantung Darah 250 cc
156 Kapas Pembalut Absorben 250 Gram
157 Kapas Berlemak 500 mg
158 Kasa Roll Panjang Besar 40x80 Cm
159 Kasa Kompres 40/40 Steril
160 Kasa Pembalut Hidrofil Steril 16 cm x 16 cm
161 Kasa Pembalut Hidrofil Supergrade 40 cm x 16 cm
162 Kasa Steril 10 cm x 10 cm
163 Keterolac Inj 30 mg
164 Ketokonazole Tab 200 mg
165 Ketokonazole Krim
166 Kinina Dihidroklorida ( Kina ) Inj 25 %-2ml
167 Kuinin Sulfat Tab 222 mg ( H2O ) (Qunine 222 mg)
168 Klorpromasin HCL Tab Salut 25 mg
169 Klorpromasin HCL Tab Salut 100 mg
170 Klorpromasin Inj 25 mg/ml-1ml
171 Klorpromasin Inj 5 mg/ ml-2ml
172 Kodein HCL ( Kodeina ) Tab 10 mg
173 Klip Plastik 7 x 10 cm
174 Klip Plastik 8 x 5 cm
175 Kertas pulvis
176 Lancet blood
177 Lidokain Com, Inj Kombinasi
178 Levofloksasin 500 mg
179 Loratadine Tablet 10 mg
180 Loperamide 10 mg
181 Maxiflow Baby (Masker Oksigen)
182 Maxiflow Anak (Masker Oksigen)
183 Maxiflow Dewasa (Masker Oksigen)
184 Masker
185 Masker Respirator N-95
186 Methilprednisolon Tablet 4 mg
187 Methilergometrin Maleat Inj 0,200 mg/ml-1ml
188 Methilergometrin Maleat Tab salut 0,125 mg
189 Meloxicam 7,5 mg
190 Meloxicam 15 mg
191 Metformin HCL Tab 500 mg
192 Metformin HCL Tab 850 mg
193 Metoklopramide Tab 10 mg
194 Metronidasol Infus 500 mg/100 ml
195 Metronidasol Tab 250 mg
196 Metronidasol Tab 500 mg
197 Mikonazol Krim / Salf 2% ( Nitrat )
198 Microlax Suppos
199 Mucus Extractor
200 Natrium Diklofenak Tab 25 mg
201 Natrium Diklofenak Tab 50 mg
202 Natrium Klorida Larutan Infus 0,9% Steril
203 Nifedipin Tab 10 mg
204 Nistatin 100.000 IU/g Tab Vaginal
205 Nistatin 500.000 IU/ Tab Salut
206 NGT No. 6
207 NGT.No. 8
208 NGT.No.12
209 NGT.No.14
210 NGT.No.18
211 Obat Batuk Hitam
212 Omeprasol Tab 20 mg
213 Ondansetron Tablet 4 mg
214 Obgyn Steril Handscoen
215 Oralit/ Garam Oralit
216 Objec Glass/Slide
217 Oxibiotic injeksi
218 Oxitetrasikllin HCL Inj I.M 50mg/ml-10ml
219 Oxitetrasikllin HCL Salep Kulit 3%
220 Oxitetrasikllin Salep Mata 1%
221 Oxitosin Inj 10 IU /ml-1ml (pitogin Injeksi)
222 Oxyflow Baby
223 Oxyflow Anak
224 Oxyflow Dewasa
225 Pap Smer Kit S
226 Pap Smer Kit M
227 Pap Smer Kit L
228 Papaverin Inj 40mg/ml
229 Papaverin Tab 40 mg
230 Parasetamol Sirup 120 mg/ml
231 Parasetamol Tab 500 mg
232 Pirantel Pamoat ( Pirantel ) Tab 125 mg
233 Piridoksin HCL ( Vit B6 ) Tab 10 mg
234 Piroxicam Tab 10 mg
235 Piroxicam Tab 20 mg
236 Plester 5 Yard x 2 Inch
237 Pirasetam Tab 400 mg
238 Pirasinamida Tab 500 mg
239 Prednison Tab 5 mg
240 Primakuin Tab 15 mg
241 Primperan Injeksi
242 Prokain Penisillin G Inj 3 Juta IU
243 Propanolol HCL ( Propanolol ) Tab 40 mg
244 Ranitidin Inj 25 mg/ml
245 Ranitidin Tab 150 mg
246 Retinol ( Vit A ) Kapsul Lunak 100.000 IU
247 Retinol ( Vit A ) Kapsul Lunak 200.000 IU
248 Retinol ( Vit A ) Kapsul Lunak 50.000 IU
249 Ringer Laktat Larutan Infus Steril
250 Rivanol Larutan (Etakridin ) 300 ml
251 Salbutamol Tab 2 mg
252 Salbutamol Tab 4 mg
253 Sefadroxil syrup 125mg/ml
254 Sefadroxil Kapsul 250 mg
255 Sefadroxil Kapsul 500 mg
256 Setirizine Tab 10 mg
257 Setirizine Suspensi
258 Semen Seng Fosfat Serbuk dan Cairan
259 Sianokobalamin (Vit B12 ) Inj 500 mcg / ml-1ml
260 Sianokobalamin ( Vit B12 ) Tab 50 mg
261 Seftriakson Inj 1 g/Vial
262 Sefotaxim Inj 1 g/ Vial
263 Simetidin Tab 200 mg
264 Simvastatin 5 mg
265 Simvastatin Tab 10 mg
266 Siprofloxasin Tab 250 mg
267 Siprofloxasin Tab 500 mg
268 Scabimite Krim
269 Sofratule (Daryantull)
270 Sohobion Injeksi
271 Silk Benang Bedah Sutera + Jarum No.2/0 75 cm
272 Silk Benang Bedah Sutera + Jarum No.3/0 75 cm
273 Sofband Gips 6 Inch
274 Sofband Gips 4 inch
275 Stik Glukosa Easy Touch
276 Stik As. Urat Easy Touch
277 Stik Kolesterol Easy Touch
278 Tetrasiklin Kapsul 250 mg
279 Tetrasiklin Kapsul 500 mg
280 Terramycin Injeksi
281 Thiamin HCL / Monoitrat (Vit B1) Tab 50 mg
282 Thiamin HCL ( Vit B1 ) Inj 100 mg/ml-1ml
283 Tranfusi Set (Blood Set)
284 Tramadol injeksi
285 Urine Bag
286 Ultra Sonic Gell
287 Under Pad 60 cm x 90 Steril With SAP
288 Ventolin injeksi (inhaler)
289 Ventolin Nebulizer
290 Vaksin Verorab (Anti Rabies)
291 Vitamin B Complex Tab
292 Vitamin B Complex Inj
293 Wing Needlee No. 23
294 Wing Needlee No. 25
295 Wing Needlee No. 27
296 Yodium Povidon Larutan 10% - 60 ml
297 Yodium Povidon Larutan 10% - 300 ml
298 Yodium Povidon Larutan 10% - 1000 ml
299 Zinc Tablet dispersible 20 mg
TOTAL HARGA

Mengetahui
Kepala Puskesmas Marsela

ROBERTH DJERSON LEWIER


NIP. 19740711 199703 1004
AS MARSELA TAHUN 2021
AN RATA-
RENCANA Harga
RATA PER JUMLAH
SATUAN KEBUTUH Satuan
BULAN HARGA (Rp)
AN 2020 (Rp)
SELAMA
c d e f g
Buah 50 900 1,100 990,000
Buah 50 900 1,750 1,575,000
Buah 50 900 779 701,100
Buah 25 450 968 435,600
Buah - - 1,375 -
Buah - - 1,500 -
Buah 5 90 3,800 342,000
Buah 20 360 3,800 1,368,000
Buah 20 360 3,800 1,368,000
Buah 5 90 3,800 342,000
Buah 5 90 4,100 369,000
Tablet - - 492 -
Botol 3 54 25,000 1,350,000
Botol - - -
Tablet 50 900 -
Tablet 50 900 108 97,200
Botol 50 900 6,095 5,485,500
Tablet 1,000 18,000 201 3,618,000
Ampul - - 3,280 -
Tablet 10 180 107 19,260
Kaplet 1,000 18,000 212 3,816,000
Kapsul 500 9,000 245 2,205,000
Botol 50 900 2,790 2,511,000
Kaplet 200 3,600 -
Kaplet 200 3,600 450 1,620,000
Vial - - 10,296 -
Botol - - -
tablet 100 1,800 99 178,200
Tablet 300 5,400 83 448,200
Tablet 1,000 18,000 3,987 71,766,000
Tablet 200 3,600 58 208,800
Botol 50 900 2,257 2,031,300
Tube 10 180 5,620 1,011,600
Tablet 25 450 2,070 931,500
Ampul 10 180 2,798 503,640
Ampul - - 26,600 -
Ampul 5 90 48,750 4,387,500
Tube 15 270 3,274 883,980
Tablet 1,500 27,000 131 3,537,000
Tablet 200 3,600 88 316,800
Kaplet - - -
Kaplet 500 9,000 195 1,755,000
Ampul 50 900 2,798 2,518,200
Tablet - - 4,312 -
Ampul 5 90 1,914 172,260
Ampul 5 90 43,183 3,886,470
Tube 25 450 4,383 1,972,350
Tablet - - 236 -
Tablet 100 1,800 414 745,200
Dus 20 360 1,142 411,120
Vial - - -
Tablet 1,000 18,000 445 8,010,000
Tube 20 360 1,520 547,200
Tablet 30 540 -
Tube 15 270 17,928 4,840,560
Ampul - - -
Tube 10 180 4,024 724,320
Tablet 200 3,600 87 313,200
Tablet - - 86 -
Pcs 15 270 5,583 1,507,410
Pcs 15 270 5,583 1,507,410
Pcs 25 450 5,583 2,512,350
Pcs 15 270 5,583 1,507,410
Ampul - - 97,220 -
Tablet 1,500 27,000 26 702,000
Kapsul 150 2,700 357 963,900
Kapsul 150 2,700 -
Tube 20 360 2,160 777,600
Botol 10 180 -
Botol 50 900 2,590 2,331,000
Tube 25 450 4,042 1,818,900
Kapsul 50 900 720 648,000
Kapsul 50 900 893 803,700
Botol 500 9,000 2,155 19,395,000
Tablet 1,000 18,000 132 2,376,000
Vial 25 450 1,378 620,100
Tablet 250 4,500 37 166,500
Ampul 5 90 2,150 193,500
Tablet - - 86 -
Tablet 100 1,800 115 207,000
Vial 25 450 1,373 617,850
Tablet - - 104 -
Tablet 50 900 -
Kapsul - - 264 -
Tablet 100 1,800 190 342,000
Tablet 50 900 166 149,400
Suppos 10 180 36,200 6,516,000
Tablet - - 153 -
Tablet 25 450 -
Buah 25 450 30,250 13,612,500
Buah 25 450 -
Botol 100 1,800 5,658 10,184,400
Ampul 25 450 2,486 1,118,700
Botol 25 450 8,183 3,682,350
Kapsul 100 1,800 693 1,247,400
Kapsul 100 1,800 704 1,267,200
Botol 50 900 6,788 6,109,200
Botol - - -
Tablet - - -
Pcs - - -
Botol - - 20,000 -
vial - - 2,325 -
Tablet 25 450 243 109,350
Botol 25 450 2,590 1,165,500
Vial 10 180 4,438 798,840
Tablet 50 900 890 801,000
Botol 5 90 30,000 2,700,000
Buah 5 90 30,000 2,700,000
Buah 5 90 30,000 2,700,000
Buah 5 90 8,000 720,000
Buah 5 90 8,000 720,000
Buah 5 90 8,000 720,000
Buah 5 90 8,000 720,000
Buah 5 90 8,000 720,000
Buah 5 90 8,000 720,000
Buah 5 90 8,000 720,000
Tablet 10 180 29,520 5,313,600
Vial 10 180 1,850 333,000
Tablet 100 1,800 88 158,400
Botol 10 180 -
Ampul - - 3,854 -
Tube 25 450 -
Botol 10 180 5,020 903,600
Tablet 50 900 273 245,700
Botol 25 450 5,200 2,340,000
Buah 10 180 28,500 5,130,000
Buah 10 180 37,500 6,750,000
Tablet 100 1,800 720 1,296,000
Tablet 2,500 45,000 132 5,940,000
Botol 10 180 6,900 1,242,000
Botol 10 180 6,840 1,231,200
Botol 10 180 -
Tablet 50 900 242 217,800
Pcs 100 1,800 -
Pcs 100 1,800 -
Pcs 100 1,800 -
Pcs 100 1,800 -
Pcs 100 1,800 6,985 12,573,000
Pcs 100 1,800 6,985 12,573,000
Tablet - - 194 -
Tube 50 900 2,846 2,561,400
Botol 50 900 5,739 5,165,100
Tablet 50 900 -
Tablet 1,000 18,000 -
Pcs 25 450 3,500 1,575,000
Pcs 25 450 3,200 1,440,000
Tablet - - -
Tablet - - 165 -
Tablet 25 450 -
Ampul - - 7,800 -
Tablet 1,000 18,000 62 1,116,000
Tablet - - 241 -
Botol 25 450 23,500 10,575,000
Roll 2 36 -
Roll - - -
Roll 10 180 22,000 3,960,000
Buah 10 180 16,500 2,970,000
Buah 1 18 105,000 1,890,000
Buah 100 1,800 1,600 2,880,000
Buah 10 180 8,000 1,440,000
Buah 10 180 36,960 6,652,800
Buah 10 180 -
Ampul 10 180 1,265 227,700
Tablet 100 1,800 311 559,800
Tube 50 900 2,893 2,603,700
Ampul - - 7,440 -
Tablet - - 799 -
Tablet - - -
Tablet - - 179 -
Ampul - - 1,550 -
Ampul - - -
Tablet - - 600 -
Pak 10 180 -
Pak 10 180 -
Pak 20 360 -
Buah 100 1,800 623 1,121,400
Ampul 100 1,800 1,433 2,579,400
Tablet 100 1,800 520 936,000
Tablet 100 1,800 185 333,000
Tablet 100 1,800 -
Pcs - - -
Pcs - - -
Pcs - - -
Botol 1,000 18,000 1,226 22,068,000
Buah 20 360 -
Tablet 200 3,600 -
Tablet - - 9,900 -
Tablet 100 1,800 185 333,000
Tablet 100 1,800 -
Tablet 100 1,800 1,719 3,094,200
Tablet 200 3,600 138 496,800
Tablet 200 3,600 168 604,800
Tablet 100 1,800 117 210,600
Botol 5 90 11,547 1,039,230
Tablet 100 1,800 99 178,200
Tablet 100 1,800 176 316,800
Tube 25 450 4,268 1,920,600
Suppos 50 900 -
Buah 25 450 -
Tablet 500 9,000 163 1,467,000
Tablet 500 9,000 162 1,458,000
Botol 15 270 6,410 1,730,700
Tablet 100 1,800 219 394,200
Tablet 25 450 858 386,100
Tablet - - 768 -
Buah 5 90 22,000 1,980,000
Buah 5 90 22,000 1,980,000
Buah 5 90 22,000 1,980,000
Buah 5 90 22,000 1,980,000
Buah 5 90 22,000 1,980,000
Botol 75 1,350 2,670 3,604,500
Tablet 150 2,700 150 405,000
Tablet 50 900 1,090 981,000
Pcs 50 900 1,500 1,350,000
Saschet 250 4,500 296 1,332,000
Pcs 200 3,600 -
Vial 50 900 -
Vial 25 450 -
Tube 100 1,800 1,259 2,266,200
Tube 100 1,800 2,600 4,680,000
Ampul 100 1,800 3,020 5,436,000
Pcs - - -
Pcs - - -
Pcs - - -
Pcs - - -
Pcs - -
Pcs - -
Ampul - - -
Tablet 50 900 -
Botol 100 1,800 1,252 2,253,600
Tablet 3,000 54,000 66 3,564,000
Tablet 500 9,000 334 3,006,000
Tablet 2,000 36,000 154 5,544,000
Tablet 500 9,000 334 3,006,000
Tablet 500 9,000 244 2,196,000
Buah 50 900 -
Tablet - - -
Tablet - - -
Tablet 1,000 18,000 91 1,638,000
Tablet 100 1,800 175 315,000
Vial - - -
Ampul - - 22,880 -
Tablet 50 900 64 57,600
Vial 100 1,800 1,540 2,772,000
Tablet 500 9,000 121 1,089,000
Kapsul 200 3,600 355 1,278,000
Kapsul 200 3,600 648 2,332,800
Kapsul - - -
Botol 25 450 7,150 3,217,500
Botol 25 450 7,200 3,240,000
Tablet 100 1,800 -
100 1,800 81 145,800
Botol 100 1,800 4,581 8,245,800
Kapsul 500 9,000 -
Kapsul 2,000 36,000 587 21,132,000
Tablet 500 9,000 103 927,000
Botol 50 900 3,192 2,872,800
Botol - - -
vial 100 1,800 1,335 2,403,000
Tablet 2,000 36,000 53 1,908,000
vial - - 5,143 -
vial - - 7,700 -
Tablet - - -
Tablet 1,000 18,000 -
Tablet 1,000 18,000 110 1,980,000
Tablet 1,000 18,000 -
Tablet 1,000 18,000 305 5,490,000
Tube 25 450 37,525 16,886,250
Pcs - - -
Ampul 100 1,800 4,740 8,532,000
Pcs - - 4,583 -
pcs - - 4,583 -
roll - - 37,500 -
Roll - - 28,500 -
Buah 500 9,000 -
Buah 500 9,000 -
Buah 500 9,000 -
Kapsul 1,000 18,000 193 3,474,000
Kapsul 1,000 18,000 348 6,264,000
Vial - - 15,300 -
Tablet 2,000 36,000 98 3,528,000
Vial - - -
Pcs - - 3,600 -
Ampul 10 180 -
pcs 10 180 3,000 540,000
Botol - 12,854 -
Pcs 10 180 -
Vial - - -
Ampul - - 28,220 -
vial - - 267,000 -
Tablet 3,000 54,000 147 7,938,000
Ampul 100 1,800 11,273 20,291,400
pcs 100 1,800 14,000 25,200,000
Pcs 100 1,800 14,000 25,200,000
Pcs 100 1,800 14,000 25,200,000
Botol 100 1,800 7,532 13,557,600
Botol - - -
Botol 10 180 79,650 14,337,000
Tablet 200 3,600 658 2,368,800
665,630,010

MARSELA, 22 JANUARI 2020


Petugas Puskesmas,

AGUNG PRATOYO, S.Farm., Apt


NRPK . 25.6.0504262
GG ctM PCT SYR AMOX
11 11 2 13
13 26 3 30
11 21 3 10
3 3 3 10
31 31 3 10
13 13 1 21
3 3 2 30
10 20 17 10
21 18 10
17 18 10
10 22 2
21 21 5
11 1 161
2 5
10 2
1 11
14 10
9 22
211 35
293
Kode Puskesmas :
Puskesmas : Marsela
Kecamatan : Pulau Masela
Puskesmas Pembantu yg Ada …………….
Kabupaten : MALUKU BARAT DAYA
Provinsi : MALUKU
LAPORAN PEMAKAIAN

KODE/N STOK
NAMA OBAT dan PERBEKALAN KESEHATAN SATUAN PENERIMAAN
O. URT AWAL

1 2 3 4 5
1 Alat Suntik Sekali Pakai 1 CC Buah 89 200
2 Alat Suntik Sekali Pakai 2,5 CC Buah 98
3 Alat Suntik Sekali Pakai 3 CC Buah 32 200
4 Alat Suntik Sekali Pakai 5 CC Buah 690 200
5 Alat Suntik Sekali Pakai 10 CC Buah -
6 Alat Suntik Sekali Pakai 20 CC Buah -
7 Abocath ( I.V. Catheter) No. 18 Buah 50
8 Abocath (I.V.Catheter) No.20 Buah 46
9 Abocath (I.V.Catheter) No.22 Buah 47
10 Abocath (I.V.Catheter) No.24 Buah 47
11 Abocath (I.V.Catheter) No.26 Buah -
12 Albendasol Tab 400 mg Tablet -
13 Alkohol 70 % 1000 ml ( Etanol ) Botol 29
14 Alkohol 70 % 100 ml ( Etanol ) Botol -
15 Allopurinol Tab 100 mg Tablet 620
16 Allopurinol Tab 300 mg Tablet -
17 Ambroxol sirup 15 mg/ml Botol -
18 Ambroxol Tab 30 mg Tablet 1,662
19 Aminofillin inj 24 mg/ml-10 ml Ampul -
20 Aminofilin Tab 200 mg Tablet - 200
21 Amoxicillin Kaplet 250 mg Kaplet 2,410
22 Amoxicillin Kapsul 500 mg Kapsul 1,000
23 Amoxicillin Sirup Kering 125 mg/ 5 ml Botol -
24 Ampisillin Kaplet 250 mg Kaplet -
25 Ampisillin Kaplet 500 mg Kaplet 700
26 Ampisillin Serbuk Inj 1.m/ i.v 1000 mg/ml Vial -
27 Ampisillin sirup Kering 125 mg/ 5 ml Botol -
28 Amlodipin 5 mg tablet tablet 3,095
29 Amlodipin 10 mg Tablet -
30 Anvomer B6 Tab Tablet -
31 Antasida Doen Tab Kombinasi Tablet 3,528
32 Antasida Doen II Suspensi Botol -

33 Anti Fungi Doen Kombinasi (Asam Bensoat 3%+As.Salisilat 6% 189


(Whitefield) Tube
34 Anti Malaria Doen Kombinasi (DHP) Tablet -
35 Aquadest Steril (Air Untuk Injeksi Ampul 25 ml) Ampul -
36 Artemeter injeksi 80 mg/ml Ampul -
37 Artesunat Injeksi Ampul -
38 Asam Salisilat 2% + Belerang Endap 4% ( salf 2-4 ) Tube -
39 Asam Askorbat ( Vit C ) Tab 50 mg Tablet 1,230
40 Asam Folat Tab 1 mg Tablet 1,710
41 Asam Mefenamat Kapsul 250 mg Kaplet -
42 Asam Mefenamat Kaplet 500 mg Kaplet 1,330
43 Asam Traneksamat injeksi 100 mg/ml Ampul -
44 Aspar - K Tab Tablet -
45 Atropina Sulfat Inj 0,25 mg/ml-1ml Ampul -
46 ATS Injeksi 1500 IU Ampul -
47 Asiklovir Krim 5 % Tube -
48 Asiklovir Tab 200 mg Tablet -
49 Asiklovir Tab 400 mg Tablet 376
50 Bedak Salysil Serbuk 2 % Dus -
51 Benzatin Bensil Penisillin 1,2 Juta IU Vial -

52 Bessi II Sulfat Tab Kombinasi : Besi II sulfat 7H2O 200 mg, Asam Tablet 1,480 2,000
Folat 0,25 mg (Fe = Tambah Darah)
53 Betametason 0,1% Krim Tube 20 100
54 Bisoprolol tab Tablet -
55 Bioplasenton gel Tube -
56 Buscopan Injeksi Ampul -
57 Bufacetin Salep Kulit Krim Tube -
58 Captopril Tablet 12,5 mg Tablet 1,557
59 Captopril Tablet 25 mg Tablet - 1,000
60 Catgut Chromic + Jarum No. 2/0 75 cm Pcs 24
61 Catgut Chromic + Jarum No. 3/0 75 cm Pcs 24
62 Catgut Plain + Jarum No.2/0 75 cm Pcs 24
63 Catgut Plain + Jarum No. 3/0 75 cm Pcs 24
64 Catapres Injeksi Ampul -
65 Chloramfeniramine Maleat (Ctm) Tablet 111 2,000
66 Chloramfenikol Kapsul 250 mg Kapsul 3,850
67 Chloramfenikol Kapsul 500 mg Kapsul -
68 Chloramfenikol Salf Mata 1% Tube -
69 Chloramfenikol Suspensi 125 mg/5 ml Botol 72
70 Chloramfenikol Tetes Telinga 3 % Botol -
71 Chloramfenikol Salep Kulit 2 % Tube -
72 Clindamiciyn 150 mg Kapsul 500
73 Clindamicin 300 mg Kapsul -
74 Cotrimoxasol Suspensi Botol -

75 Cotrimoxasol Tab kombinasi : Sulfametoksazole 400mg , Tablet -


Trimetroprim 80 mg
76 Dexamethason Inj 5 mg/ml-1 ml Vial 100
77 Dexamethason Tab 0,5 mg Tablet 209 2,000
78 Diazepam Inj 5mg/ml-2ml Ampul 30
79 Diazepam Tab 2 mg Tablet -
80 Diazepam Tab 5 mg Tablet 226
81 Difenhidramin HCL Inj 10 mg/ml-1 ml Vial 100
82 Digoxin Tab 0,25 mg Tablet -
83 Dimenhidrinat Tablet 50 mg Tablet -
84 Doksisiklik Kapsul 100 mg Kapsul -
85 Domperidon Tab 10 mg Tablet 743
86 Dulcolax Tab Tablet -
87 Dulcolax Suppos Suppos -
88 Diltiasem HCL Tab 30 mg Tablet -
89 Efedrin HCL ( Efedrina ) Tab 25 mg Tablet -
90 Elastic Verband 4 Inchi Buah 10
91 Elastic Verband 6 Inchi Buah -
92 Erlamycetin Tetes Telinga Botol -
93 Epinefrin HCL / Bitartrat ( Adrenalin ) Inj. 0,1%-1ml Ampul -
94 ErLamycetin Tetes Mata Botol -
95 Eritr0misin Kapsul 250 mg Kapsul -
96 Eritromisin Kapsul 500 mg Kapsul 170
97 Eritromisin Sirup 200 mg/5 ml Botol 75
98 Etil Klorida Spray Botol -
99 Etambutol HCL ( Etambutol ) Tab 250 mg Tablet -
100 Extension Tube Pcs -
101 Eugenol cairan Botol -
102 Fenobarbital Inj 50 mg/ml-2ml vial -
103 Fenobarbital Tab 30 mg Tablet -
104 Fenol Gliseron tetes telinga 10 % Botol 24
105 Fitomenadion ( Vit K1 ) Inj 10 mg/ml-1ml Vial -
106 Fitomenadion ( Vit K1 ) Tab Salut 10 mg Tablet 5,105
107 Foley Catheter T. 6 Botol -
108 Foley Catheter T. 8 Buah 10
109 Foley Catheter T.10 Buah 10
110 Foley Catheter T.12 Buah 10
111 Foley Catheter T.14 Buah 10
112 Foley Catheter T. 16 Buah 10
113 Foley Catheter T.18 Buah 10
114 Foley Catheter T. 20 Buah 10
115 Foley Catheter T. 22 Buah 10
116 Foley Catheter T. 24 Buah 10
117 Flagystatin Tablet Vagina Tablet -
118 Furosemida Inj i.v i.m 10 mg/ml Vial -
119 Furosemida Tab 40 mg Tablet 270
120 Formalin Cairan Botol -
121 Gentamisin Inj 80 mg/ 2ml Ampul -
122 Gentamisin Salf Kulit 0,1 % Tube 10
123 Gentamisin Slufat Tetes Mata 0,3 % Botol -
124 Glimepride Tab 4 mg Tablet -
125 Gentian Violet Larutan 1 % Botol 13
126 Gipsonal Gipsum 4 Inchi Buah -
127 Gipsonal Gipsum 6 Inchi Buah -
128 Glibenclamide Tab Tablet 735
129 Gliseril Guaiakolat Tab 100 mg/ Guafenisine Tablet 634 1,000
130 Glukosa Larutan Infus 5 % Steril Botol - 20
131 Glukosa Larutan Infus 10 % Steril Botol -
132 Glukosa Larutan Infus 40 % Steril Botol -
133 Griseovulvin Tab 125 mg, Micronized Tablet 2,038
134 Handscoen S Pcs -
135 Handscoen M Pcs 200
136 Handscoen L Pcs 200
137 Handscoen No. 6 Pcs -
138 Handscoen No.7 Pcs 100
139 Handscoen No.7,5 Pcs 100
140 Hidroklorotiasida ( HCT ) Tab 25 mg Tablet -
141 Hidrokortison Krim 2,5 mg Tube 86
142 Ibuprofen Suspensi Botol 46
143 Ibuprofen Tab 200 mg Tablet -
144 Ibuprofen Tab 400 mg Tablet -
145 Infusion Set Anak Pcs - 150
146 Infusion Set Dewasa Pcs 33
147 Isoniasid ( INH ) Tab 100 mg Tablet -
148 Isoniasid ( INH ) Tab 300 mg Tablet -
149 Isosorbid Dinitrat Tab Sublingual 5 mg Tablet -
150 Kalium Glukonat injeksi 10% (100mg/ml) Ampul -
151 Kalsium Laktat ( Kalk ) Tab 500 mg Tablet 1,250
152 Karbamasepin Tab 200 mg Tablet -
KAEN-3B Larutan infus (mengandung NaCl 1,75+KCL 1,5gr+ Na
153 Lactat 2,24 gr, Dextrose 27 gr) Botol -

154 Kapas Putih 1000 gr (Kapas Putih 1 Kg) Roll - 4


155 Kantung Darah 250 cc Roll -
156 Kapas Pembalut Absorben 250 Gram Roll -
157 Kapas Berlemak 500 mg Buah 5
158 Kasa Roll Panjang Besar 40x80 Cm Buah 5
159 Kasa Kompres 40/40 Steril Buah 305
160 Kasa Pembalut Hidrofil Steril 16 cm x 16 cm Buah 10
161 Kasa Pembalut Hidrofil Supergrade 40 cm x 16 cm Buah -
162 Kasa Steril 10 cm x 10 cm Buah 3,200
163 Keterolac Inj 30 mg Ampul -
164 Ketokonazole Tab 200 mg Tablet 1,120
165 Ketokonazole Krim Tube 42
166 Kinina Dihidroklorida ( Kina ) Inj 25 %-2ml Ampul -
167 Kuinin Sulfat Tab 222 mg ( H2O ) (Qunine 222 mg) Tablet 300
168 Klorpromasin HCL Tab Salut 25 mg Tablet -
169 Klorpromasin HCL Tab Salut 100 mg Tablet 200
170 Klorpromasin Inj 25 mg/ml-1ml Ampul -
171 Klorpromasin Inj 5 mg/ ml-2ml Ampul -
172 Kodein HCL ( Kodeina ) Tab 10 mg Tablet -
173 Klip Plastik 7 x 10 cm Pak -
174 Klip Plastik 8 x 5 cm Pak -
175 Kertas pulvis Pak -
176 Lancet blood Buah -
177 Lidokain Com, Inj Kombinasi Ampul 30 50
178 Levofloksasin 500 mg Tablet -
179 Loratadine Tablet 10 mg Tablet -
180 Loperamide 10 mg Tablet -
181 Maxiflow Baby (Masker Oksigen) Pcs -
182 Maxiflow Anak (Masker Oksigen) Pcs -
183 Maxiflow Dewasa (Masker Oksigen) Pcs -
184 Masker Botol 15 20
185 Masker Respirator N-95 Buah - 5
186 Methilprednisolon Tablet 4 mg Tablet -
187 Methilergometrin Maleat Inj 0,200 mg/ml-1ml Tablet -
188 Methilergometrin Maleat Tab salut 0,125 mg Tablet -
189 Meloxicam 7,5 mg Tablet -
190 Meloxicam 15 mg Tablet -
191 Metformin HCL Tab 500 mg Tablet 1,140
192 Metformin HCL Tab 850 mg Tablet 500
193 Metoklopramide Tab 10 mg Tablet 1,800
194 Metronidasol Infus 500 mg/100 ml Botol 36
195 Metronidasol Tab 250 mg Tablet -
196 Metronidasol Tab 500 mg Tablet -
197 Mikonazol Krim / Salf 2% ( Nitrat ) Tube 24
198 Microlax Suppos Suppos -
199 Mucus Extractor Buah -
200 Natrium Diklofenak Tab 25 mg Tablet 2,940
201 Natrium Diklofenak Tab 50 mg Tablet 4,050
202 Natrium Klorida Larutan Infus 0,9% Steril Botol -
203 Nifedipin Tab 10 mg Tablet 60
204 Nistatin 100.000 IU/g Tab Vaginal Tablet 100
205 Nistatin 500.000 IU/ Tab Salut Tablet -
206 NGT No. 6 Buah -
207 NGT.No. 8 Buah -
208 NGT.No.12 Buah -
209 NGT.No.14 Buah -
210 NGT.No.18 Buah -
211 Obat Batuk Hitam Botol 10
212 Omeprasol Tab 20 mg Tablet 20 800
213 Ondansetron Tablet 4 mg Tablet -
214 Obgyn Steril Handscoen Pcs 100
215 Oralit/ Garam Oralit Saschet - 500
216 Objec Glass/Slide Pcs -
217 Oxibiotic injeksi Vial -
218 Oxitetrasikllin HCL Inj I.M 50mg/ml-10ml Vial -
219 Oxitetrasikllin HCL Salep Kulit 3% Tube -
220 Oxitetrasikllin Salep Mata 1% Tube -
221 Oxitosin Inj 10 IU /ml-1ml (pitogin Injeksi) Ampul -
222 Oxyflow Baby Pcs -
223 Oxyflow Anak Pcs -
224 Oxyflow Dewasa Pcs -
225 Pap Smer Kit S Pcs -
226 Pap Smer Kit M Pcs -
227 Pap Smer Kit L Pcs -
228 Papaverin Inj 40mg/ml Ampul -
229 Papaverin Tab 40 mg Tablet -
230 Parasetamol Sirup 120 mg/ml Botol 69
231 Parasetamol Tab 500 mg Tablet 905 3,000
232 Pirantel Pamoat ( Pirantel ) Tab 125 mg Tablet 132
233 Piridoksin HCL ( Vit B6 ) Tab 10 mg Tablet 500
234 Piroxicam Tab 10 mg Tablet 3,625
235 Piroxicam Tab 20 mg Tablet -
236 Plester 5 Yard x 2 Inch Buah 24
237 Pirasetam Tab 400 mg Tablet -
238 Pirasinamida Tab 500 mg Tablet -
239 Prednison Tab 5 mg Tablet 480 500
240 Primakuin Tab 15 mg Tablet 2,000
241 Primperan Injeksi Vial -
242 Prokain Penisillin G Inj 3 Juta IU Ampul -
243 Propanolol HCL ( Propanolol ) Tab 40 mg Tablet -
244 Ranitidin Inj 25 mg/ml Vial -
245 Ranitidin Tab 150 mg Tablet 4,750
246 Retinol ( Vit A ) Kapsul Lunak 100.000 IU Kapsul 100 500
247 Retinol ( Vit A ) Kapsul Lunak 200.000 IU Kapsul 842
248 Retinol ( Vit A ) Kapsul Lunak 50.000 IU Kapsul -
249 Ringer Laktat Larutan Infus Steril Botol 52
250 Rivanol Larutan (Etakridin ) 300 ml Botol -
251 Salbutamol Tab 2 mg Tablet - 1,000
252 Salbutamol Tab 4 mg -
253 Sefadroxil syrup 125mg/ml Botol -
254 Sefadroxil Kapsul 250 mg Kapsul -
255 Sefadroxil Kapsul 500 mg Kapsul - 1,000
256 Setirizine Tab 10 mg Tablet 420
257 Setirizine Suspensi Botol -
258 Semen Seng Fosfat Serbuk dan Cairan Botol -
259 Sianokobalamin (Vit B12 ) Inj 500 mcg / ml-1ml vial 58
260 Sianokobalamin ( Vit B12 ) Tab 50 mg Tablet 5,994
261 Seftriakson Inj 1 g/Vial vial -
262 Sefotaxim Inj 1 g/ Vial vial -
263 Simetidin Tab 200 mg Tablet -
264 Simvastatin 5 mg Tablet -
265 Simvastatin Tab 10 mg Tablet - 500
266 Siprofloxasin Tab 250 mg Tablet -
267 Siprofloxasin Tab 500 mg Tablet 430
268 Scabimite Krim Tube 9
269 Sofratule (Daryantull) Pcs -
270 Sohobion Injeksi Ampul -
271 Silk Benang Bedah Sutera + Jarum No.2/0 75 cm Pcs 36
272 Silk Benang Bedah Sutera + Jarum No.3/0 75 cm pcs 36
273 Sofband Gips 6 Inch roll -
274 Sofband Gips 4 inch Roll -
275 Stik Glukosa Easy Touch Buah -
276 Stik As. Urat Easy Touch Buah -
277 Stik Kolesterol Easy Touch Buah -
278 Tetrasiklin Kapsul 250 mg Kapsul -
279 Tetrasiklin Kapsul 500 mg Kapsul 1,750
280 Terramycin Injeksi Vial 10
281 Thiamin HCL / Monoitrat (Vit B1) Tab 50 mg Tablet - 1,500
282 Thiamin HCL ( Vit B1 ) Inj 100 mg/ml-1ml Vial -
283 Tranfusi Set (Blood Set) Pcs -
284 Tramadol injeksi Ampul -
285 Urine Bag pcs 25
286 Ultra Sonic Gell Botol -
287 Under Pad 60 cm x 90 Steril With SAP Pcs -
288 Ventolin injeksi (inhaler) Vial -
289 Ventolin Nebulizer Ampul -
290 Vaksin Verorab (Anti Rabies) vial -
291 Vitamin B Complex Tab Tablet - 3,000
292 Vitamin B Complex Inj Ampul 10
293 Wing Needlee No. 23 pcs -
294 Wing Needlee No. 25 Pcs -
295 Wing Needlee No. 27 Pcs -
296 Yodium Povidon Larutan 10% - 60 ml Botol -
297 Yodium Povidon Larutan 10% - 300 ml Botol -
298 Yodium Povidon Larutan 10% - 1000 ml Botol 2 10
299 Zinc Tablet dispersible 20 mg Tablet 2 500
300 Fituno Tablet - 300
TOTAL HARGA
DAFTAR TAMB
1

UMUM
JUMLAH KUNJUNGAN RESEP
BAYAR TIDAK BAYAR
0 126

Mengetahui/Menyetujui; Yang Menyerahkan;


Kepala Dinas Kesehatan Kabupaten Petugas Gudang Farmasi,
Maluku Barat Daya,

NIP. NIP.
BULAN
TAHUN

N PEMAKAIAN DAN LEMBAR PERMINTAAN OBAT (LPLPO)

Kadaluwarsa/R STOK Harga


PERSEDIAAN PEMAKAIAN SISA STOK PERMINTAAN
usak APT Satuan (Rp)

6 7 8 9 10 11 12
289 - - 289 - 1,100
98 - - 98 1,750
232 - - 232 779
890 - - 890 968
#VALUE! - 185 #VALUE! 1,375
- - - - 1,500
50 - - 50 3,800
46 - - 46 3,800
47 - - 47 3,800
47 - - 47 3,800
- - - - 4,100
- - - - 492
29 - - 29 25,000
- - - -
620 30 - 590
- - - - 108
- - - - 6,095
1,662 41 - 1,621 201
- - - - 3,280
200 - - 200 107
2,410 189 - 2,221 212
1,000 - - 1,000 245
- - - - 2,790
- - - -
700 70 - 630 450
- - - - 10,296
- - - -
3,095 - - 3,095 99
- - - - 83
- - - - 3,987
3,528 60 - 3,468 58
- - - - 2,257

189 - - 189 5,620

- - - - 2,070
- - - - 2,798
- - - - 26,600
- - - - 48,750
- - - - 3,274
1,230 150 - 1,080 131
1,710 160 - 1,550 88
- - - -
1,330 170 - 1,160 195
- - - - 2,798
- - - - 4,312
- - - - 1,914
- - - - 43,183
- - - - 4,383
- - - - 236
376 19 - 357 414
- - - - 1,142
- - - -

3,480 221 1,259 2,000 445

120 6 114 1,520


- - - -
- - - - 17,928
- - - -
- - - - 4,024
1,557 50 1,507 87
1,000 - - 1,000 86
24 - - 24 5,583
24 - - 24 5,583
24 - - 24 5,583
24 - - 24 5,583
- - - - 97,220
2,111 332 1,779 26
3,850 332 - 3,518 357
- - - -
- - - - 2,160
72 - - 72
- - - - 2,590
- - - - 4,042
500 10 - 490 720
- - - - 893
- - - - 2,155

- - - - 132

100 20 - 80 1,378
2,209 100 2,109 37
30 - - 30 2,150
- - - - 86
226 4 - 222 115
100 - - 100 1,373
- - - - 104
- - - -
- - - - 264
743 20 723 190
- - - - 166
- - - - 36,200
- - - - 153
- - - -
10 - - 10 30,250
- - - -
- - - - 5,658
- - - - 2,486
- - - - 8,183
- - - - 693
170 - - 170 704
75 - - 75 6,788
- - - -
- - - -
- - - -
- - - - 20,000
- - - - 2,325
- - - - 243
24 1 - 23 2,590
- - - - 4,438
5,105 - - 5,105 890
- - - - 30,000
10 - - 10 30,000
10 - - 10 30,000
10 - - 10 8,000
10 - - 10 8,000
10 - - 10 8,000
10 - - 10 8,000
10 - - 10 8,000
10 - - 10 8,000
10 - - 10 8,000
- - - - 29,520
- - - - 1,850
270 - - 270 88
- - - -
- - - - 3,854
10 - - 10
- - - - 5,020
- - - - 273
13 1 - 12 5,200
- - - - 28,500
- - - - 37,500
735 - - 735 720
1,634 272 1,362 132
20 - - 20 6,900
- - - - 6,840
- - - -
2,038 20 - 2,018 242
- - -
200 - 200
200 - - 200
- - - -
100 - - 100 6,985
100 - - 100 6,985
- - - - 194
86 5 - 81 2,846
46 9 37 - 5,739
- - - -
- - - -
150 - 150 - 3,500
33 - - 33 3,200
- - - -
- - - - 165
- - - -
- - - - 7,800
1,250 120 - 1,130 62
- - - - 241

- - - - 23,500

4 - 4
- - - -
- - - - 22,000
5 - 5 16,500
5 - - 5 105,000
305 - - 305 1,600
10 - - 10 8,000
- - - - 36,960
3,200 - - 3,200
- - - - 1,265
1,120 30 - 1,090 311
42 2 - 40 2,893
- - - - 7,440
300 - - 300 799
- - - -
200 - - 200 179
- - - - 1,550
- - - -
- - - - 600
- - - -
- - - -
- - - -
- - - - 623
80 - - 80 1,433
- - - - 520
- - - - 185
- - -
- - - -
- - - -
- - - -
35 - - 35 1,226
5 - - 5
- - - -
- - - - 9,900
- - - - 185
- - - -
- - - - 1,719
1,140 - - 1,140 138
500 - - 500 168
1,800 - - 1,800 117
36 - - 36 11,547
- - - - 99
- - - - 176
24 - - 24 4,268
- - - -
- - - -
2,940 - - 2,940 163
4,050 100 - 3,950 162
- - - 6,410
60 10 - 50 219
100 - - 100 858
- - - - 768
- - - - 22,000
- - - - 22,000
- - - - 22,000
- - - - 22,000
- - - - 22,000
10 - - 10 2,670
820 50 - 770 150
- - - - 1,090
100 - - 100 1,500
500 5 1,700 (1,205) 296
- - - -
- - - -
- - - -
- - 2 (2) 1,259
- - - - 2,600
- - - - 3,020
- - - -
- - - -
- - - -
- - - -
- - -
- - -
- - - -
- - - -
69 17 52 - 1,252
3,905 420 - 3,485 66
132 - - 132 334
500 110 - 390 154
3,625 60 - 3,565 334
- - - - 244
24 - - 24
- - - -
- - - -
980 64 - 916 91
2,000 - - 2,000 175
- - - -
- - - - 22,880
- - - - 64
- - - - 1,540
4,750 130 - 4,620 121
600 - - 600 355
842 97 - 745 648
- - - -
52 - - 52 7,150
- - - - 7,200
1,000 22 - 978
- - - 81
- - - - 4,581
- - - -
1,000 - - 1,000 587
420 87 - 333 103
- - - - 3,192
- - - -
58 11 - 47 1,335
5,994 - 5,994 53
- - - - 5,143
- - - - 7,700
- - - -
- - -
500 - - 500 110
- - - -
430 - - 430 305
9 1 - 8 37,525
- - - -
- - - - 4,740
36 - - 36 4,583
36 - - 36 4,583
- - - - 37,500
- - - - 28,500
- - - -
- - - -
- - - -
- - - - 193
1,750 - - 1,750 348
10 - - 10 15,300
1,500 20 - 1,480 98
- - - -
- - - - 3,600
- - - -
25 - - 25 3,000
- - - - 12,854
- - - -
- - - -
- - - - 28,220
- - - - 267,000
3,000 50 - 2,950 147
10 - - 10 11,273
- - - - 14,000
- - - - 14,000
- - - - 14,000
- - - - 7,532
- - - -
12 1 - 11 79,650
502 70 - 432 658
- - 658
RGA
DAFTAR TAMBAHAN LPLPO PUSKESMAS MARSELA DESEMBER 2019

UM
ASKES JUMLAH
TIDAK BAYAR
105 231

Yang Meminta;
Pimpinan Puskesmas,

ROBERT DJ. LEWIER


NIP. 19740711 1997 1004
; Desember
: 2019

O)

Total Harga Total Harga Total Harga


Kadaluwarsa/R
Penerimaan Pemakaian Sisa Stock KET
usak (Rp)
(Rp) (Rp) (Rp)

13 14 15 16 17
220,000 - - 317,900
- - - 171,500
155,800 - - 180,728
193,600 - - 861,520
- - 254,375 #VALUE!
- - - -
- - - 190,000
- - - 174,800
- - - 178,600
- - - 178,600
- - - -
- - - -
- - - 725,000
- - - -
- - - -
- - - -
- - - -
- 8,241 - 325,821
- - - -
21,400 - - 21,400
- 40,068 - 470,852
- - - 245,000
- - - -
- - - -
- 31,500 - 283,500
- - - -
- - - -
- - - 306,405
- - - -
- - - -
- 3,480 - 201,144
- - - -

- - - 1,062,180

- - - -
- - - -
- - - -
- - - -
- - - -
- 19,650 - 141,480
- 14,080 - 136,400
- - - -
- 33,150 - 226,200
- - - -
- - - -
- - - -
- - - -
- - - -
- - - -
- 7,866 - 147,798
- - - -
- - - -

890,000 98,345 560,255 890,000

152,000 9,120 - 173,280


- - - -
- - - -
- - - -
- - - -
- 4,350 - 131,109
86,000 - - 86,000
- - - 133,992
- - - 133,992
- - - 133,992
- - - 133,992
- - - -
52,000 8,632 - 46,254
- 118,524 - 1,255,926
- - - -
- - - -
- - - -
- - - -
- - - -
- 7,200 - 352,800
- - - -
- - - -

- - - -

- 27,560 - 110,240
74,000 3,700 - 78,033
- - - 64,500
- - - -
- 460 - 25,530
- - - 137,300
- - - -
- - - -
- - - -
- 3,800 - 137,370
- - - -
- - - -
- - - -
- - - -
- - - 302,500
- - - -
- - - -
- - - -
- - - -
- - - -
- - - 119,680
- - - 509,100
- - - -
- - - -
- - - -
- - - -
- - - -
- - - -
- 2,590 - 59,570
- - - -
- - - 4,543,450
- - - -
- - - 300,000
- - - 300,000
- - - 80,000
- - - 80,000
- - - 80,000
- - - 80,000
- - - 80,000
- - - 80,000
- - - 80,000
- - - -
- - - -
- - - 23,760
- - - -
- - - -
- - - -
- - - -
- - - -
- 5,200 - 62,400
- - - -
- - - -
- - - 529,200
132,000 35,904 - 179,784
138,000 - - 138,000
- - - -
- - - -
- 4,840 - 488,356
- - - -
- - - -
- - - -
- - - -
- - - 698,500
- - - 698,500
- - - -
- 14,230 - 230,526
- 51,651 212,343 -
- - - -
- - - -
525,000 - 525,000 -
- - - 105,600
- - - -
- - - -
- - - -
- - - -
- 7,440 - 70,060
- - - -

- - - -

- - - -
- - - -
- - - -
- - - 82,500
- - - 525,000
- - - 488,000
- - - 80,000
- - - -
- - - -
- - - -
- 9,330 - 338,990
- 5,786 - 115,720
- - - -
- - - 239,700
- - - -
- - - 35,800
- - - -
- - - -
- - - -
- - - -
- - - -
- - - -
- - - -
71,650 - - 114,640
- - - -
- - - -
- - - -
- - - -
- - - -
- - - -
24,520 - - 42,910
- - - -
- - - -
- - - -
- - - -
- - - -
- - - -
- - - 157,320
- - - 84,000
- - - 210,600
- - - 415,692
- - - -
- - - -
- - - 102,432
- - - -
- - - -
- - - 479,220
- 16,200 - 639,900
- - - -
- 2,190 - 10,950
- - - 85,800
- - - -
- - - -
- - - -
- - - -
- - - -
- - - -
- - - 26,700
120,000 7,500 - 115,500
- - - -
- - - 150,000
148,000 1,480 503,200 (356,680)
- - - -
- - - -
- - - -
- - 2,518 (2,518)
- - - -
- - - -
- - - -
- - - -
- - - -
- - - -
- - - -
- - - -
- - - -
- - - -
- 21,284 65,104 -
198,000 27,720 - 230,010
- - - 44,088
- 16,940 - 60,060
- 20,040 - 1,190,710
- - - -
- - - -
- - - -
- - - -
45,500 5,824 - 83,356
- - - 350,000
- - - -
- - - -
- - - -
- - - -
- 15,730 - 559,020
177,500 - - 213,000
- 62,856 - 482,760
- - - -
- - - 371,800
- - - -
- - - -
- - - -
- - - -
- - - -
587,000 - - 587,000
- 8,961 - 34,299
- - - -
- - - -
- 14,685 - 62,745
- - - 317,682
- - - -
- - - -
- - - -
- - - -
55,000 - - 55,000
- - - -
- - - 131,150
- 37,525 - 300,200
- - - -
- - - -
- - - 164,988
- - - 164,988
- - - -
- - - -
- - - -
- - - -
- - - -
- - - -
- - - 609,000
- - - 153,000
147,000 1,960 - 145,040
- - - -
- - - -
- - - -
- - - 75,000
- - - -
- - - -
- - - -
- - - -
- - - -
441,000 7,350 - 433,650
- - - 112,730
- - - -
- - - -
- - - -
- - - -
- - - -
796,500 79,650 - 876,150
329,000 46,060 - 284,256
197,400 - - -
5,977,870 970,652 2,122,795 #VALUE!

5 JANUARI 2019

Yang Menerima;
Petugas Puskesmas,

AGUNG PRATOYO, S.Farm., Apt


NRPK. 25.6.05.04262
Kode Puskesmas :
Puskesmas : Marsela
Kecamatan : Pulau Masela
Puskesmas Pembantu yg IBLATMUNTAH
Kabupaten : MALUKU BARAT DAYA
Provinsi : MALUKU
LAPORAN PEMAKAIAN D

KODE/N STOK
NAMA OBAT dan PERBEKALAN KESEHATAN SATUAN PENERIMAAN
O. URT AWAL

1 2 3 4 5
1 Alat Suntik Sekali Pakai 1 CC Buah 100
2 Alat Suntik Sekali Pakai 2,5 CC Buah 100
3 Alat Suntik Sekali Pakai 3 CC Buah 100
4 Alat Suntik Sekali Pakai 5 CC Buah 775
5 Alat Suntik Sekali Pakai 10 CC Buah -
6 Alat Suntik Sekali Pakai 20 CC Buah -
7 Abocath ( I.V. Catheter) No. 18 Buah 50
8 Abocath (I.V.Catheter) No.20 Buah 50
9 Abocath (I.V.Catheter) No.22 Buah 47
10 Abocath (I.V.Catheter) No.24 Buah 47
11 Abocath (I.V.Catheter) No.26 Buah -
12 Albendasol Tab 400 mg Tablet -
13 Alkohol 70 % 1000 ml ( Etanol ) Botol 29
14 Alkohol 70 % 100 ml ( Etanol ) Botol -
15 Allopurinol Tab 100 mg Tablet 650
16 Allopurinol Tab 300 mg Tablet -
17 Ambroxol sirup 15 mg/ml Botol -
18 Ambroxol Tab 30 mg Tablet 1,772
19 Aminofillin inj 24 mg/ml-10 ml Ampul -
20 Aminofilin Tab 200 mg Tablet 500
21 Amoxicillin Kaplet 250 mg Kaplet 2,720
22 Amoxicillin Kapsul 500 mg Kapsul 1,000
23 Amoxicillin Sirup Kering 125 mg/ 5 ml Botol -
24 Ampisillin Kaplet 250 mg Kaplet -
25 Ampisillin Kaplet 500 mg Kaplet 780
26 Ampisillin Serbuk Inj 1.m/ i.v 1000 mg/ml Vial -
27 Ampisillin sirup Kering 125 mg/ 5 ml Botol -
28 Amlodipin 5 mg tablet tablet 3,145
29 Amlodipin 10 mg Tablet -
30 Anvomer B6 Tab Tablet -
31 Antasida Doen Tab Kombinasi Tablet 3,938
32 Antasida Doen II Suspensi Botol -

33 Anti Fungi Doen Kombinasi (Asam Bensoat 3%+As.Salisilat 6% 189


(Whitefield) Tube
34 Anti Malaria Doen Kombinasi (DHP) Tablet -
35 Aquadest Steril (Air Untuk Injeksi Ampul 25 ml) Ampul -
36 Artemeter injeksi 80 mg/ml Ampul -
37 Artesunat Injeksi Ampul -
38 Asam Salisilat 2% + Belerang Endap 4% ( salf 2-4 ) Tube -
39 Asam Askorbat ( Vit C ) Tab 50 mg Tablet 1,230
40 Asam Folat Tab 1 mg Tablet 1,710
41 Asam Mefenamat Kapsul 250 mg Kaplet -
42 Asam Mefenamat Kaplet 500 mg Kaplet 1,550
43 Asam Traneksamat injeksi 100 mg/ml Ampul -
44 Aspar - K Tab Tablet -
45 Atropina Sulfat Inj 0,25 mg/ml-1ml Ampul -
46 ATS Injeksi 1500 IU Ampul -
47 Asiklovir Krim 5 % Tube -
48 Asiklovir Tab 200 mg Tablet -
49 Asiklovir Tab 400 mg Tablet 410
50 Bedak Salysil Serbuk 2 % Dus -
51 Benzatin Bensil Penisillin 1,2 Juta IU Vial -

52 Bessi II Sulfat Tab Kombinasi : Besi II sulfat 7H2O 200 mg, Asam Tablet 1,660
Folat 0,25 mg (Fe = Tambah Darah)
53 Betametason 0,1% Krim Tube 25
54 Bisoprolol tab Tablet -
55 Bioplasenton gel Tube -
56 Buscopan Injeksi Ampul -
57 Bufacetin Salep Kulit Krim Tube -
58 Captopril Tablet 12,5 mg Tablet 1,677
59 Captopril Tablet 25 mg Tablet -
60 Catgut Chromic + Jarum No. 2/0 75 cm Pcs 24
61 Catgut Chromic + Jarum No. 3/0 75 cm Pcs 24
62 Catgut Plain + Jarum No.2/0 75 cm Pcs 24
63 Catgut Plain + Jarum No. 3/0 75 cm Pcs 24
64 Catapres Injeksi Ampul -
65 Chloramfeniramine Maleat (Ctm) Tablet 1,311
66 Chloramfenikol Kapsul 250 mg Kapsul 3,850
67 Chloramfenikol Kapsul 500 mg Kapsul -
68 Chloramfenikol Salf Mata 1% Tube -
69 Chloramfenikol Suspensi 125 mg/5 ml Botol 72
70 Chloramfenikol Tetes Telinga 3 % Botol -
71 Chloramfenikol Salep Kulit 2 % Tube -
72 Clindamiciyn 150 mg Kapsul 500
73 Clindamicin 300 mg Kapsul -
74 Cotrimoxasol Suspensi Botol -

75 Cotrimoxasol Tab kombinasi : Sulfametoksazole 400mg , Tablet -


Trimetroprim 80 mg
76 Dexamethason Inj 5 mg/ml-1 ml Vial 100
77 Dexamethason Tab 0,5 mg Tablet 270
78 Diazepam Inj 5mg/ml-2ml Ampul 30
79 Diazepam Tab 2 mg Tablet -
80 Diazepam Tab 5 mg Tablet 226
81 Difenhidramin HCL Inj 10 mg/ml-1 ml Vial 100
82 Digoxin Tab 0,25 mg Tablet -
83 Dimenhidrinat Tablet 50 mg Tablet -
84 Doksisiklik Kapsul 100 mg Kapsul -
85 Domperidon Tab 10 mg Tablet 793
86 Dulcolax Tab Tablet -
87 Dulcolax Suppos Suppos -
88 Diltiasem HCL Tab 30 mg Tablet -
89 Efedrin HCL ( Efedrina ) Tab 25 mg Tablet -
90 Elastic Verband 4 Inchi Buah 10
91 Elastic Verband 6 Inchi Buah -
92 Erlamycetin Tetes Telinga Botol -
93 Epinefrin HCL / Bitartrat ( Adrenalin ) Inj. 0,1%-1ml Ampul -
94 ErLamycetin Tetes Mata Botol -
95 Eritr0misin Kapsul 250 mg Kapsul -
96 Eritromisin Kapsul 500 mg Kapsul 170
97 Eritromisin Sirup 200 mg/5 ml Botol 78
98 Etil Klorida Spray Botol -
99 Etambutol HCL ( Etambutol ) Tab 250 mg Tablet -
100 Extension Tube Pcs -
101 Eugenol cairan Botol -
102 Fenobarbital Inj 50 mg/ml-2ml vial -
103 Fenobarbital Tab 30 mg Tablet -
104 Fenol Gliseron tetes telinga 10 % Botol 26
105 Fitomenadion ( Vit K1 ) Inj 10 mg/ml-1ml Vial -
106 Fitomenadion ( Vit K1 ) Tab Salut 10 mg Tablet 5,105
107 Foley Catheter T. 6 Botol -
108 Foley Catheter T. 8 Buah 10
109 Foley Catheter T.10 Buah 10
110 Foley Catheter T.12 Buah 10
111 Foley Catheter T.14 Buah 10
112 Foley Catheter T. 16 Buah 10
113 Foley Catheter T.18 Buah 10
114 Foley Catheter T. 20 Buah 10
115 Foley Catheter T. 22 Buah 10
116 Foley Catheter T. 24 Buah 10
117 Flagystatin Tablet Vagina Tablet -
118 Furosemida Inj i.v i.m 10 mg/ml Vial -
119 Furosemida Tab 40 mg Tablet 270
120 Formalin Cairan Botol -
121 Gentamisin Inj 80 mg/ 2ml Ampul -
122 Gentamisin Salf Kulit 0,1 % Tube 10
123 Gentamisin Slufat Tetes Mata 0,3 % Botol -
124 Glimepride Tab 4 mg Tablet -
125 Gentian Violet Larutan 1 % Botol 14
126 Gipsonal Gipsum 4 Inchi Buah -
127 Gipsonal Gipsum 6 Inchi Buah -
128 Glibenclamide Tab Tablet 735
129 Gliseril Guaiakolat Tab 100 mg/ Guafenisine Tablet 2,384
130 Glukosa Larutan Infus 5 % Steril Botol -
131 Glukosa Larutan Infus 10 % Steril Botol -
132 Glukosa Larutan Infus 40 % Steril Botol -
133 Griseovulvin Tab 125 mg, Micronized Tablet 2,088
134 Handscoen S Pcs -
135 Handscoen M Pcs 200
136 Handscoen L Pcs 200
137 Handscoen No. 6 Pcs -
138 Handscoen No.7 Pcs 100
139 Handscoen No.7,5 Pcs 100
140 Hidroklorotiasida ( HCT ) Tab 25 mg Tablet -
141 Hidrokortison Krim 2,5 mg Tube 86
142 Ibuprofen Suspensi Botol 92
143 Ibuprofen Tab 200 mg Tablet -
144 Ibuprofen Tab 400 mg Tablet -
145 Infusion Set Anak Pcs -
146 Infusion Set Dewasa Pcs 40
147 Isoniasid ( INH ) Tab 100 mg Tablet -
148 Isoniasid ( INH ) Tab 300 mg Tablet -
149 Isosorbid Dinitrat Tab Sublingual 5 mg Tablet -
150 Kalium Glukonat injeksi 10% (100mg/ml) Ampul -
151 Kalsium Laktat ( Kalk ) Tab 500 mg Tablet 1,420
152 Karbamasepin Tab 200 mg Tablet -
KAEN-3B Larutan infus (mengandung NaCl 1,75+KCL 1,5gr+ Na
153 Lactat 2,24 gr, Dextrose 27 gr) Botol -

154 Kapas Putih 1000 gr (Kapas Putih 1 Kg) Roll 1


155 Kantung Darah 250 cc Roll -
156 Kapas Pembalut Absorben 250 Gram Roll -
157 Kapas Berlemak 500 mg Buah 5
158 Kasa Roll Panjang Besar 40x80 Cm Buah 5
159 Kasa Kompres 40/40 Steril Buah 325
160 Kasa Pembalut Hidrofil Steril 16 cm x 16 cm Buah 10
161 Kasa Pembalut Hidrofil Supergrade 40 cm x 16 cm Buah -
162 Kasa Steril 10 cm x 10 cm Buah 3,200
163 Keterolac Inj 30 mg Ampul -
164 Ketokonazole Tab 200 mg Tablet 1,130
165 Ketokonazole Krim Tube 45
166 Kinina Dihidroklorida ( Kina ) Inj 25 %-2ml Ampul -
167 Kuinin Sulfat Tab 222 mg ( H2O ) (Qunine 222 mg) Tablet 300
168 Klorpromasin HCL Tab Salut 25 mg Tablet -
169 Klorpromasin HCL Tab Salut 100 mg Tablet 200
170 Klorpromasin Inj 25 mg/ml-1ml Ampul -
171 Klorpromasin Inj 5 mg/ ml-2ml Ampul -
172 Kodein HCL ( Kodeina ) Tab 10 mg Tablet -
173 Klip Plastik 7 x 10 cm Pak -
174 Klip Plastik 8 x 5 cm Pak -
175 Kertas pulvis Pak -
176 Lancet blood Buah -
177 Lidokain Com, Inj Kombinasi Ampul 30
178 Levofloksasin 500 mg Tablet -
179 Loratadine Tablet 10 mg Tablet -
180 Loperamide 10 mg Tablet -
181 Maxiflow Baby (Masker Oksigen) Pcs -
182 Maxiflow Anak (Masker Oksigen) Pcs -
183 Maxiflow Dewasa (Masker Oksigen) Pcs -
184 Masker Botol 15
185 Masker Respirator N-95 Buah -
186 Methilprednisolon Tablet 4 mg Tablet -
187 Methilergometrin Maleat Inj 0,200 mg/ml-1ml Tablet -
188 Methilergometrin Maleat Tab salut 0,125 mg Tablet -
189 Meloxicam 7,5 mg Tablet -
190 Meloxicam 15 mg Tablet -
191 Metformin HCL Tab 500 mg Tablet 1,140
192 Metformin HCL Tab 850 mg Tablet 500
193 Metoklopramide Tab 10 mg Tablet 1,800
194 Metronidasol Infus 500 mg/100 ml Botol 36
195 Metronidasol Tab 250 mg Tablet -
196 Metronidasol Tab 500 mg Tablet -
197 Mikonazol Krim / Salf 2% ( Nitrat ) Tube 24
198 Microlax Suppos Suppos -
199 Mucus Extractor Buah -
200 Natrium Diklofenak Tab 25 mg Tablet 2,940
201 Natrium Diklofenak Tab 50 mg Tablet 4,250
202 Natrium Klorida Larutan Infus 0,9% Steril Botol -
203 Nifedipin Tab 10 mg Tablet 60
204 Nistatin 100.000 IU/g Tab Vaginal Tablet 100
205 Nistatin 500.000 IU/ Tab Salut Tablet -
206 NGT No. 6 Buah -
207 NGT.No. 8 Buah -
208 NGT.No.12 Buah -
209 NGT.No.14 Buah -
210 NGT.No.18 Buah -
211 Obat Batuk Hitam Botol 10
212 Omeprasol Tab 20 mg Tablet 115
213 Ondansetron Tablet 4 mg Tablet -
214 Obgyn Steril Handscoen Pcs 100
215 Oralit/ Garam Oralit Saschet -
216 Objec Glass/Slide Pcs -
217 Oxibiotic injeksi Vial -
218 Oxitetrasikllin HCL Inj I.M 50mg/ml-10ml Vial -
219 Oxitetrasikllin HCL Salep Kulit 3% Tube -
220 Oxitetrasikllin Salep Mata 1% Tube -
221 Oxitosin Inj 10 IU /ml-1ml (pitogin Injeksi) Ampul -
222 Oxyflow Baby Pcs -
223 Oxyflow Anak Pcs -
224 Oxyflow Dewasa Pcs -
225 Pap Smer Kit S Pcs -
226 Pap Smer Kit M Pcs -
227 Pap Smer Kit L Pcs -
228 Papaverin Inj 40mg/ml Ampul -
229 Papaverin Tab 40 mg Tablet -
230 Parasetamol Sirup 120 mg/ml Botol 69
231 Parasetamol Tab 500 mg Tablet 905
232 Pirantel Pamoat ( Pirantel ) Tab 125 mg Tablet 132
233 Piridoksin HCL ( Vit B6 ) Tab 10 mg Tablet 500
234 Piroxicam Tab 10 mg Tablet 3,625
235 Piroxicam Tab 20 mg Tablet -
236 Plester 5 Yard x 2 Inch Buah 24
237 Pirasetam Tab 400 mg Tablet -
238 Pirasinamida Tab 500 mg Tablet -
239 Prednison Tab 5 mg Tablet 480
240 Primakuin Tab 15 mg Tablet 2,000
241 Primperan Injeksi Vial -
242 Prokain Penisillin G Inj 3 Juta IU Ampul -
243 Propanolol HCL ( Propanolol ) Tab 40 mg Tablet -
244 Ranitidin Inj 25 mg/ml Vial -
245 Ranitidin Tab 150 mg Tablet 4,750
246 Retinol ( Vit A ) Kapsul Lunak 100.000 IU Kapsul 100
247 Retinol ( Vit A ) Kapsul Lunak 200.000 IU Kapsul 842
248 Retinol ( Vit A ) Kapsul Lunak 50.000 IU Kapsul -
249 Ringer Laktat Larutan Infus Steril Botol 52
250 Rivanol Larutan (Etakridin ) 300 ml Botol -
251 Salbutamol Tab 2 mg Tablet -
252 Salbutamol Tab 4 mg -
253 Sefadroxil syrup 125mg/ml Botol -
254 Sefadroxil Kapsul 250 mg Kapsul -
255 Sefadroxil Kapsul 500 mg Kapsul -
256 Setirizine Tab 10 mg Tablet 470
257 Setirizine Suspensi Botol -
258 Semen Seng Fosfat Serbuk dan Cairan Botol -
259 Sianokobalamin (Vit B12 ) Inj 500 mcg / ml-1ml vial 100
260 Sianokobalamin ( Vit B12 ) Tab 50 mg Tablet 6,094
261 Seftriakson Inj 1 g/Vial vial -
262 Sefotaxim Inj 1 g/ Vial vial -
263 Simetidin Tab 200 mg Tablet -
264 Simvastatin 5 mg Tablet -
265 Simvastatin Tab 10 mg Tablet -
266 Siprofloxasin Tab 250 mg Tablet -
267 Siprofloxasin Tab 500 mg Tablet 470
268 Scabimite Krim Tube 9
269 Sofratule (Daryantull) Pcs -
270 Sohobion Injeksi Ampul -
271 Silk Benang Bedah Sutera + Jarum No.2/0 75 cm Pcs 36
272 Silk Benang Bedah Sutera + Jarum No.3/0 75 cm pcs 36
273 Sofband Gips 6 Inch roll -
274 Sofband Gips 4 inch Roll -
275 Stik Glukosa Easy Touch Buah -
276 Stik As. Urat Easy Touch Buah -
277 Stik Kolesterol Easy Touch Buah -
278 Tetrasiklin Kapsul 250 mg Kapsul -
279 Tetrasiklin Kapsul 500 mg Kapsul 1,750
280 Terramycin Injeksi Vial 10
281 Thiamin HCL / Monoitrat (Vit B1) Tab 50 mg Tablet 209
282 Thiamin HCL ( Vit B1 ) Inj 100 mg/ml-1ml Vial -
283 Tranfusi Set (Blood Set) Pcs -
284 Tramadol injeksi Ampul -
285 Urine Bag pcs 25
286 Ultra Sonic Gell Botol -
287 Under Pad 60 cm x 90 Steril With SAP Pcs -
288 Ventolin injeksi (inhaler) Vial -
289 Ventolin Nebulizer Ampul -
290 Vaksin Verorab (Anti Rabies) vial -
291 Vitamin B Complex Tab Tablet -
292 Vitamin B Complex Inj Ampul 10
293 Wing Needlee No. 23 pcs -
294 Wing Needlee No. 25 Pcs -
295 Wing Needlee No. 27 Pcs -
296 Yodium Povidon Larutan 10% - 60 ml Botol -
297 Yodium Povidon Larutan 10% - 300 ml Botol -
298 Yodium Povidon Larutan 10% - 1000 ml Botol 3
299 Zinc Tablet dispersible 20 mg Tablet 4,570
300 Caviplex Tablet 3,702
TOTAL HARGA

DAFTAR TAMBAHA
1

UMUM
JUMLAH KUNJUNGAN RESEP
BAYAR TIDAK BAYAR
0 162

Mengetahui/Menyetujui; Yang Menyerahkan;


Kepala Dinas Kesehatan Kabupaten Petugas Gudang Farmasi,
Maluku Barat Daya,

NIP. NIP.
BULAN ; JANUARI
TAHUN : 2020

N PEMAKAIAN DAN LEMBAR PERMINTAAN OBAT (LPLPO)

Total Harga
Kadaluwarsa/R STOK Harga
PERSEDIAAN PEMAKAIAN SISA STOK PERMINTAAN Penerimaan
usak APT Satuan (Rp)
(Rp)

6 7 8 9 10 11 12 13
100 11 - 89 200 1,100 -
100 2 - 98 200 1,750 -
100 68 - 32 200 779 -
775 85 - 690 200 968 -
- - - - 1,375 -
- - - - 1,500 -
50 - - 50 3,800 -
50 4 - 46 3,800 -
47 - - 47 3,800 -
47 - - 47 3,800 -
- - - - 4,100 -
- - - - 492 -
29 - - 29 25,000 -
- - - - -
650 30 - 620 -
- - - - 108 -
- - - - 6,095 -
1,772 110 - 1,662 1,000 201 -
- - - - 3,280 -
500 - 500 - 1,000 107 -
2,720 310 - 2,410 212 -
1,000 - - 1,000 245 -
- - - - 2,790 -
- - - - -
780 80 - 700 450 -
- - - - 10,296 -
- - - - -
3,145 50 - 3,095 99 -
- - - - 83 -
- - - - 3,987 -
3,938 410 - 3,528 58 -
- - - - 2,257 -

189 - - 189 5,620 -

- - - - 2,070 -
- - - - 2,798 -
- - - - 26,600 -
- - - - 48,750 -
- - - - 3,274 -
1,230 - - 1,230 131 -
1,710 - - 1,710 88 -
- - - - -
1,550 220 - 1,330 195 -
- - - - 2,798 -
- - - - 4,312 -
- - - - 1,914 -
- - - - 43,183 -
- - - - 200 4,383 -
- - - 236 -
410 34 - 376 1,000 414 -
- - - 20 1,142 -
- - - - -

1,660 180 - 1,480 2,000 445 -

25 5 - 20 100 1,520 -
- - - - 1,000 -
- - - - 100 17,928 -
- - - - -
- - - - 4,024 -
1,677 120 - 1,557 3,000 87 -
- - - - 86 -
24 - - 24 5,583 -
24 - - 24 5,583 -
24 - - 24 5,583 -
24 - - 24 5,583 -
- - - - 97,220 -
1,311 1,200 - 111 2,000 26 -
3,850 - - 3,850 357 -
- - - - -
- - - - 100 2,160 -
72 - - 72 -
- - - - 50 2,590 -
- - - - 50 4,042 -
500 - - 500 720 -
- - - - 893 -
- - - - 2,155 -

- - - - 1,000 132 -

100 - - 100 1,378 -


270 61 - 209 1,000 37 -
30 - - 30 2,150 -
- - - - 86 -
226 - - 226 115 -
100 - - 100 1,373 -
- - - - 200 104 -
- - - - 1,000 -
- - - - 264 -
793 50 - 743 190 -
- - - - 1,000 166 -
- - - - 50 36,200 -
- - - - 153 -
- - - - -
10 - - 10 30,250 -
- - - - -
- - - - 50 5,658 -
- - - - 100 2,486 -
- - - - 50 8,183 -
- - - - 693 -
170 - - 170 704 -
78 3 - 75 6,788 -
- - - - -
- - - - -
- - - - -
- - - - 20,000 -
- - - - 2,325 -
- - - - 243 -
26 2 - 24 2,590 -
- - - - 4,438 -
5,105 - - 5,105 890 -
- - - - 30,000 -
10 - - 10 30,000 -
10 - - 10 30,000 -
10 - - 10 8,000 -
10 - - 10 8,000 -
10 - - 10 8,000 -
10 - - 10 8,000 -
10 - - 10 8,000 -
10 - - 10 8,000 -
10 - - 10 8,000 -
- - - - 29,520 -
- - - - 1,850 -
270 - - 270 88 -
- - - - 5 -
- - - - 3,854 -
10 - - 10 -
- - - - 50 5,020 -
- - - - 273 -
14 1 - 13 5,200 -
- - - - 28,500 -
- - - - 37,500 -
735 - - 735 720 -
2,384 1,750 - 634 1,000 132 -
- - - - 6,900 -
- - - - 6,840 -
- - - - -
2,088 50 - 2,038 242 -
- - - - -
200 - - 200 -
200 - - 200 -
- - - - -
100 - - 100 6,985 -
100 - - 100 6,985 -
- - - - 194 -
86 - - 86 2,846 -
92 46 - 46 5,739 -
- - - - -
- - - - -
- - - - 150 3,500 -
40 7 - 33 3,200 -
- - - - -
- - - - 165 -
- - - - -
- - - - 7,800 -
1,420 170 - 1,250 62 -
- - - - 241 -

- - - - 60 23,500 -

1 1 - - 4 -
- - - - -
- - - - 22,000 -
5 - - 5 16,500 -
5 - - 5 105,000 -
325 20 - 305 1,600 -
10 - - 10 8,000 -
- - - - 36,960 -
3,200 - - 3,200 -
- - - - 50 1,265 -
1,130 10 - 1,120 311 -
45 3 - 42 2,893 -
- - - - 7,440 -
300 - - 300 799 -
- - - - -
200 - - 200 179 -
- - - - 1,550 -
- - - - -
- - - - 600 -
- - - - 5,000 -
- - - - 5,000 -
- - - - 10,000 -
- - - - 623 -
30 - - 30 1,433 -
- - - - 520 -
- - - - 1,000 185 -
- - - - 1,000 -
- - - - 1,000 -
- - - - -
- - - - -
15 - - 15 20 1,226 -
- - - - 100 -
- - - - 1,000 -
- - - - 9,900 -
- - - - 185 -
- - - - -
- - - - 1,719 -
1,140 - - 1,140 138 -
500 - - 500 168 -
1,800 - - 1,800 117 -
36 - - 36 11,547 -
- - - - 99 -
- - - - 176 -
24 - - 24 4,268 -
- - - - -
- - - - -
2,940 - - 2,940 163 -
4,250 200 - 4,050 162 -
- - - - 6,410 -
60 - - 60 219 -
100 - - 100 858 -
- - - - 768 -
- - - - 22,000 -
- - - - 22,000 -
- - - - 22,000 -
- - - - 22,000 -
- - - - 22,000 -
10 - - 10 200 2,670 -
115 95 - 20 800 150 -
- - - - 1,090 -
100 - - 100 1,500 -
- - - - 1,000 296 -
- - - - -
- - - - -
- - - - -
- - - - 1,259 -
- - - - 2,600 -
- - - - 3,020 -
- - - - -
- - - - -
- - - - -
- - - - -
- - - - -
- - - - -
- - - - -
- - - - -
69 - - 69 200 1,252 -
905 - - 905 6,000 66 -
132 - - 132 334 -
500 - - 500 154 -
3,625 - - 3,625 334 -
- - - - 244 -
24 - - 24 -
- - - - -
- - - - -
480 - - 480 500 91 -
2,000 - - 2,000 175 -
- - - - -
- - - - 22,880 -
- - - - 64 -
- - - - 1,540 -
4,750 - - 4,750 121 -
100 - - 100 500 355 -
842 - - 842 648 -
- - - - -
52 - - 52 7,150 -
- - - - 7,200 -
- - - - -
- - - - 81 -
- - - - 200 4,581 -
- - - - 1,000 -
- - - - 587 -
470 50 - 420 103 -
- - - - 100 3,192 -
- - - - -
100 42 - 58 1,335 -
6,094 100 - 5,994 53 -
- - - - 5,143 -
- - - - 7,700 -
- - - - -
- - - - -
- - - - 500 110 -
- - - - -
470 40 - 430 305 -
9 - - 9 37,525 -
- - - - -
- - - - 4,740 -
36 - - 36 4,583 -
36 - - 36 4,583 -
- - - - 37,500 -
- - - - 28,500 -
- - - - -
- - - - -
- - - - -
- - - - 193 -
1,750 - - 1,750 348 -
10 - - 10 15,300 -
209 209 - - 3,000 98 -
- - - - 50 -
- - - - 3,600 -
- - - - -
25 - - 25 3,000 -
- - - - 12,854 -
- - - - -
- - - - 50 -
- - - - 10 28,220 -
- - - - 267,000 -
- - - - 3,000 147 -
10 - - 10 100 11,273 -
- - - - 200 14,000 -
- - - - 200 14,000 -
- - - - 200 14,000 -
- - - - 20 7,532 -
- - - - -
3 1 - 2 10 79,650 -
4,570 100 - 4,470 1,000 658 -
- 3,000
RGA -

DAFTAR TAMBAHAN LPLPO PUSKESMAS MARSELA DESEMBER 2019

UM
ASKES JUMLAH
TIDAK BAYAR
153 315

Yang Meminta;
Pimpinan Puskesmas,

ROBERT DJ. LEWIER


NIP. 19740711 1997 1004
Total Harga Total Harga
Kadaluwarsa/R
Pemakaian Sisa Stock KET
usak (Rp)
(Rp) (Rp)

14 15 16 17
12,100 - 97,900
3,500 - 171,500
52,972 - 24,928
82,280 - 667,920
- - #VALUE!
- - -
- - 190,000
15,200 - 174,800
- - 178,600
- - 178,600
- - -
- - -
- - 725,000
- - -
- - -
- - -
- - -
22,110 - 334,062
- - -
- 53,500 -
65,720 - 510,920
- - 245,000
- - -
- - -
36,000 - 315,000
- - -
- - -
4,950 - 306,405
- - -
- - -
23,780 - 204,624
- - -

- - 1,062,180

- - -
- - -
- - -
- - -
- - -
- - 161,130
- - 150,480
- - -
42,900 - 259,350
- - -
- - -
- - -
- - -
- - -
- - -
14,076 - 155,664
- - -
- - -

80,100 - 658,600

7,600 - 30,400
- - -
- - -
- - -
- - -
10,440 - 135,459
- - -
- - 133,992
- - 133,992
- - 133,992
- - 133,992
- - -
31,200 - 2,886
- - 1,374,450
- - -
- - -
- - -
- - -
- - -
- - 360,000
- - -
- - -

- - -

- - 137,800
2,257 - 7,733
- - 64,500
- - -
- - 25,990
- - 137,300
- - -
- - -
- - -
9,500 - 141,170
- - -
- - -
- - -
- - -
- - 302,500
- - -
- - -
- - -
- - -
- - -
- - 119,680
20,364 - 509,100
- - -
- - -
- - -
- - -
- - -
- - -
5,180 - 62,160
- - -
- - 4,543,450
- - -
- - 300,000
- - 300,000
- - 80,000
- - 80,000
- - 80,000
- - 80,000
- - 80,000
- - 80,000
- - 80,000
- - -
- - -
- - 23,760
- - -
- - -
- - -
- - -
- - -
5,200 - 67,600
- - -
- - -
- - 529,200
231,000 - 83,688
- - -
- - -
- - -
12,100 - 493,196
- - -
- - -
- - -
- - -
- - 698,500
- - 698,500
- - -
- - 244,756
263,994 - 263,994
- - -
- - -
- - -
22,400 - 105,600
- - -
- - -
- - -
- - -
10,540 - 77,500
- - -

- - -

- - -
- - -
- - -
- - 82,500
- - 525,000
32,000 - 488,000
- - 80,000
- - -
- - -
- - -
3,110 - 348,320
8,679 - 121,506
- - -
- - 239,700
- - -
- - 35,800
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - 42,990
- - -
- - -
- - -
- - -
- - -
- - -
- - 18,390
- - -
- - -
- - -
- - -
- - -
- - -
- - 157,320
- - 84,000
- - 210,600
- - 415,692
- - -
- - -
- - 102,432
- - -
- - -
- - 479,220
32,400 - 656,100
- - -
- - 13,140
- - 85,800
- - -
- - -
- - -
- - -
- - -
- - -
- - 26,700
14,250 - 3,000
- - -
- - 150,000
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - 86,388
- - 59,730
- - 44,088
- - 77,000
- - 1,210,750
- - -
- - -
- - -
- - -
- - 43,680
- - 350,000
- - -
- - -
- - -
- - -
- - 574,750
- - 35,500
- - 545,616
- - -
- - 371,800
- - -
- - -
- - -
- - -
- - -
- - -
5,150 - 43,260
- - -
- - -
56,070 - 77,430
5,300 - 317,682
- - -
- - -
- - -
- - -
- - -
- - -
12,200 - 131,150
- - 337,725
- - -
- - -
- - 164,988
- - 164,988
- - -
- - -
- - -
- - -
- - -
- - -
- - 609,000
- - 153,000
20,482 - -
- - -
- - -
- - -
- - 75,000
- - -
- - -
- - -
- - -
- - -
- - -
- - 112,730
- - -
- - -
- - -
- - -
- - -
79,650 - 159,300
65,800 - 2,941,260

1,422,554 53,500 #VALUE!

2-Feb-20

Yang Menerima;
Petugas Puskesmas,

AGUNG PRATOYO, S.Farm., Apt


NRPK. 25.6.05.04262
Kode Puskesmas :
Puskesmas : Marsela
Kecamatan : Pulau Masela BULAN ; Desember
Puskesmas Pembantu yg Ada ……………. TAHUN : 2019
Kabupaten : MALUKU BARAT DAYA
Provinsi : MALUKU
LAPORAN PEMAKAIAN DAN LEMBAR PERMINTAAN OBAT (LPLPO)

Total Harga Total Harga Total Harga


KODE/N STOK Kadaluwarsa/R STOK Harga Kadaluwarsa/R
NAMA OBAT dan PERBEKALAN KESEHATAN SATUAN PENERIMAAN PERSEDIAAN PEMAKAIAN SISA STOK PERMINTAAN Penerimaan Pemakaian Sisa Stock KET
O. URT AWAL usak APT Satuan (Rp) usak (Rp)
(Rp) (Rp) (Rp)

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
1 Alat Suntik Sekali Pakai 1 CC Buah 100 100 - - 100 - 1,100 110,000 - - 110,000
2 Alat Suntik Sekali Pakai 2,5 CC Buah - 100 100 - - 100 1,750 175,000 - - 175,000
3 Alat Suntik Sekali Pakai 3 CC Buah - 100 100 - - 100 779 77,900 - - 77,900
4 Alat Suntik Sekali Pakai 5 CC Buah 775 - 775 - - 775 968 - - - 750,200
5 Alat Suntik Sekali Pakai 10 CC Buah 185 - 185 - 185 - 1,375 - - 254,375 -
6 Alat Suntik Sekali Pakai 20 CC Buah - - - - - - 1,500 - - - -
7 Abocath ( I.V. Catheter) No. 18 Buah - 50 50 - - 50 3,800 190,000 - - 190,000
8 Abocath (I.V.Catheter) No.20 Buah - 50 50 - - 50 3,800 190,000 - - 190,000
9 Abocath (I.V.Catheter) No.22 Buah - 50 50 3 - 47 3,800 190,000 11,400 - 178,600
10 Abocath (I.V.Catheter) No.24 Buah - 50 50 3 - 47 3,800 190,000 11,400 - 178,600
11 Abocath (I.V.Catheter) No.26 Buah - - - - - - 4,100 - - - -
12 Albendasol Tab 400 mg Tablet - - - - - - 492 - - - -
13 Alkohol 70 % 1000 ml ( Etanol ) Botol 31 - 31 2 - 29 25,000 - 50,000 - 725,000
14 Alkohol 70 % 100 ml ( Etanol ) Botol - - - - - - - - - -
15 Allopurinol Tab 100 mg Tablet 670 - 670 20 - 650 - - - -
16 Allopurinol Tab 300 mg Tablet - - - - - - 108 - - - -
17 Ambroxol sirup 15 mg/ml Botol - - - - - - 6,095 - - - -
18 Ambroxol Tab 30 mg Tablet 1,572 200 1,772 - - 1,772 201 40,200 - - 356,172
19 Aminofillin inj 24 mg/ml-10 ml Ampul - - - - - - 3,280 - - - -
20 Aminofilin Tab 200 mg Tablet 500 - 500 - - 500 107 - - - 53,500
21 Amoxicillin Kaplet 250 mg Kaplet 3,120 - 3,120 400 - 2,720 212 - 84,800 - 576,640
22 Amoxicillin Kapsul 500 mg Kapsul - 1,000 1,000 - - 1,000 245 245,000 - - 245,000
23 Amoxicillin Sirup Kering 125 mg/ 5 ml Botol - - - - - - 2,790 - - - -
24 Ampisillin Kaplet 250 mg Kaplet - - - - - - - - - -
25 Ampisillin Kaplet 500 mg Kaplet 800 - 800 20 - 780 450 - 9,000 - 351,000
26 Ampisillin Serbuk Inj 1.m/ i.v 1000 mg/ml Vial - - - - - - 10,296 - - - -
27 Ampisillin sirup Kering 125 mg/ 5 ml Botol - - - - - - - - - -
28 Amlodipin 5 mg tablet tablet 2,665 500 3,165 20 - 3,145 99 49,500 1,980 - 311,355
29 Amlodipin 10 mg Tablet - - - - - - 83 - - - -
30 Anvomer B6 Tab Tablet - - - - - - 3,987 - - - -
31 Antasida Doen Tab Kombinasi Tablet 3,738 300 4,038 100 - 3,938 58 17,400 5,800 - 228,404
32 Antasida Doen II Suspensi Botol - - - - - 2,257 - - - -

33 Anti Fungi Doen Kombinasi (Asam Bensoat 3%+As.Salisilat 6% 189 - 189 - - 189 5,620 - - - 1,062,180
(Whitefield) Tube
34 Anti Malaria Doen Kombinasi (DHP) Tablet - - - - - - 2,070 - - - -
35 Aquadest Steril (Air Untuk Injeksi Ampul 25 ml) Ampul - - - - - - 2,798 - - - -
36 Artemeter injeksi 80 mg/ml Ampul - - - - - - 26,600 - - - -
37 Artesunat Injeksi Ampul - - - - - - 48,750 - - - -
38 Asam Salisilat 2% + Belerang Endap 4% ( salf 2-4 ) Tube - - - - - - 3,274 - - - -
39 Asam Askorbat ( Vit C ) Tab 50 mg Tablet 1,430 - 1,430 200 - 1,230 131 - 26,200 - 161,130
40 Asam Folat Tab 1 mg Tablet 1,800 - 1,800 90 - 1,710 88 - 7,920 - 150,480
41 Asam Mefenamat Kapsul 250 mg Kaplet - - - - - - - - - -
42 Asam Mefenamat Kaplet 500 mg Kaplet 150 1,500 1,650 100 - 1,550 195 292,500 19,500 - 302,250
43 Asam Traneksamat injeksi 100 mg/ml Ampul - - - - - - 2,798 - - - -
44 Aspar - K Tab Tablet - - - - - - 4,312 - - - -
45 Atropina Sulfat Inj 0,25 mg/ml-1ml Ampul - - - - - - 1,914 - - - -
46 ATS Injeksi 1500 IU Ampul - - - - - - 43,183 - - - -
47 Asiklovir Krim 5 % Tube - - - - - - 200 4,383 - - - -
48 Asiklovir Tab 200 mg Tablet - - - - - - 236 - - - -
49 Asiklovir Tab 400 mg Tablet 410 - 410 - - 410 1,000 414 - - - 169,740
50 Bedak Salysil Serbuk 2 % Dus - - - - - - 20 1,142 - - - -
51 Benzatin Bensil Penisillin 1,2 Juta IU Vial - - - - - - - - - -

52 Bessi II Sulfat Tab Kombinasi : Besi II sulfat 7H2O 200 mg, Asam Tablet 1,760 - 1,760 100 - 1,660 2,000 445 - 44,500 - 738,700
Folat 0,25 mg (Fe = Tambah Darah)
53 Betametason 0,1% Krim Tube 30 - 30 5 25 100 1,520 - 7,600 - 38,000
54 Bisoprolol tab Tablet - - - - - - 1,000 - - - -
55 Bioplasenton gel Tube - - - - - - 100 17,928 - - - -
56 Buscopan Injeksi Ampul - - - - - - - - - -
57 Bufacetin Salep Kulit Krim Tube - - - - - - 4,024 - - - -
58 Captopril Tablet 12,5 mg Tablet 1,727 - 1,727 50 1,677 87 - 4,350 - 145,899

LPLPO/KAB MBD Page 102


1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
59 Captopril Tablet 25 mg Tablet - - - - - - 86 - - - -
60 Catgut Chromic + Jarum No. 2/0 75 cm Pcs - 24 24 - - 24 5,583 133,992 - - 133,992
61 Catgut Chromic + Jarum No. 3/0 75 cm Pcs - 24 24 - - 24 5,583 133,992 - - 133,992
62 Catgut Plain + Jarum No.2/0 75 cm Pcs - 24 24 - - 24 5,583 133,992 - - 133,992
63 Catgut Plain + Jarum No. 3/0 75 cm Pcs - 24 24 - - 24 5,583 133,992 - - 133,992
64 Catapres Injeksi Ampul - - - - - - 97,220 - - - -
65 Chloramfeniramine Maleat (Ctm) Tablet 11 2,000 2,011 700 1,311 2,000 26 52,000 18,200 - 34,086
66 Chloramfenikol Kapsul 250 mg Kapsul 3,850 - 3,850 - - 3,850 357 - - - 1,374,450
67 Chloramfenikol Kapsul 500 mg Kapsul - - - - - - - - - -
68 Chloramfenikol Salf Mata 1% Tube - - - - - - 100 2,160 - - - -
69 Chloramfenikol Suspensi 125 mg/5 ml Botol 72 - 72 - - 72 - - - -
70 Chloramfenikol Tetes Telinga 3 % Botol - - - - - - 50 2,590 - - - -
71 Chloramfenikol Salep Kulit 2 % Tube - - - - - - 50 4,042 - - - -
72 Clindamiciyn 150 mg Kapsul 500 - 500 - - 500 720 - - - 360,000
73 Clindamicin 300 mg Kapsul - - - - - - 893 - - - -
74 Cotrimoxasol Suspensi Botol - - - - - - 2,155 - - - -

75 Cotrimoxasol Tab kombinasi : Sulfametoksazole 400mg , Tablet - - - - - - 1,000 132 - - - -


Trimetroprim 80 mg
76 Dexamethason Inj 5 mg/ml-1 ml Vial - 100 100 - - 100 1,378 137,800 - - 137,800
77 Dexamethason Tab 0,5 mg Tablet - 300 300 30 270 1,000 37 11,100 1,110 - 9,990
78 Diazepam Inj 5mg/ml-2ml Ampul 30 - 30 - - 30 2,150 - - - 64,500
79 Diazepam Tab 2 mg Tablet - - - - - - 86 - - - -
80 Diazepam Tab 5 mg Tablet 226 - 226 - - 226 115 - - - 25,990
81 Difenhidramin HCL Inj 10 mg/ml-1 ml Vial - 100 100 - - 100 1,373 137,300 - - 137,300
82 Digoxin Tab 0,25 mg Tablet - - - - - - 200 104 - - - -
83 Dimenhidrinat Tablet 50 mg Tablet - - - - - - 1,000 - - - -
84 Doksisiklik Kapsul 100 mg Kapsul - - - - - - 264 - - - -
85 Domperidon Tab 10 mg Tablet 813 - 813 20 793 190 - 3,800 - 150,670
86 Dulcolax Tab Tablet - - - - - - 1,000 166 - - - -
87 Dulcolax Suppos Suppos - - - - - - 50 36,200 - - - -
88 Diltiasem HCL Tab 30 mg Tablet - - - - - - 153 - - - -
89 Efedrin HCL ( Efedrina ) Tab 25 mg Tablet - - - - - - - - - -
90 Elastic Verband 4 Inchi Buah 10 - 10 - - 10 30,250 - - - 302,500
91 Elastic Verband 6 Inchi Buah - - - - - - - - - -
92 Erlamycetin Tetes Telinga Botol - - - - - - 50 5,658 - - - -
93 Epinefrin HCL / Bitartrat ( Adrenalin ) Inj. 0,1%-1ml Ampul - - - - - - 100 2,486 - - - -
94 ErLamycetin Tetes Mata Botol 1 - 1 1 - - 50 8,183 - 8,183 - -
95 Eritr0misin Kapsul 250 mg Kapsul - - - - - - 693 - - - -
96 Eritromisin Kapsul 500 mg Kapsul 170 - 170 - - 170 704 - - - 119,680
97 Eritromisin Sirup 200 mg/5 ml Botol 78 - 78 - - 78 6,788 - - - 529,464
98 Etil Klorida Spray Botol - - - - - - - - - -
99 Etambutol HCL ( Etambutol ) Tab 250 mg Tablet - - - - - - - - - -
100 Extension Tube Pcs - - - - - - - - - -
101 Eugenol cairan Botol - - - - - - 20,000 - - - -
102 Fenobarbital Inj 50 mg/ml-2ml vial - - - - - - 2,325 - - - -
103 Fenobarbital Tab 30 mg Tablet - - - - - - 243 - - - -
104 Fenol Gliseron tetes telinga 10 % Botol 3 24 27 1 - 26 2,590 62,160 2,590 - 67,340
105 Fitomenadion ( Vit K1 ) Inj 10 mg/ml-1ml Vial - - - - - - 4,438 - - - -
106 Fitomenadion ( Vit K1 ) Tab Salut 10 mg Tablet 5,105 - 5,105 - - 5,105 890 - - - 4,543,450
107 Foley Catheter T. 6 Botol - - - - - - 30,000 - - - -
108 Foley Catheter T. 8 Buah - 10 10 - - 10 30,000 300,000 - - 300,000
109 Foley Catheter T.10 Buah - 10 10 - - 10 30,000 300,000 - - 300,000
110 Foley Catheter T.12 Buah - 10 10 - - 10 8,000 80,000 - - 80,000
111 Foley Catheter T.14 Buah - 10 10 - - 10 8,000 80,000 - - 80,000
112 Foley Catheter T. 16 Buah - 10 10 - - 10 8,000 80,000 - - 80,000
113 Foley Catheter T.18 Buah - 10 10 - - 10 8,000 80,000 - - 80,000
114 Foley Catheter T. 20 Buah - 10 10 - - 10 8,000 80,000 - - 80,000
115 Foley Catheter T. 22 Buah - 10 10 - - 10 8,000 80,000 - - 80,000
116 Foley Catheter T. 24 Buah - 10 10 - - 10 8,000 80,000 - - 80,000
117 Flagystatin Tablet Vagina Tablet - - - - - - 29,520 - - - -
118 Furosemida Inj i.v i.m 10 mg/ml Vial - - - - - - 1,850 - - - -
119 Furosemida Tab 40 mg Tablet 270 - 270 - - 270 88 - - - 23,760
120 Formalin Cairan Botol - - - - - - 5 - - - -
121 Gentamisin Inj 80 mg/ 2ml Ampul - - - - - - 3,854 - - - -
122 Gentamisin Salf Kulit 0,1 % Tube 10 - 10 - - 10 - - - -
123 Gentamisin Slufat Tetes Mata 0,3 % Botol - - - - - - 50 5,020 - - - -
124 Glimepride Tab 4 mg Tablet - - - - - - 273 - - - -
125 Gentian Violet Larutan 1 % Botol 15 - 15 1 - 14 5,200 - 5,200 - 72,800
126 Gipsonal Gipsum 4 Inchi Buah - - - - - - 28,500 - - - -
127 Gipsonal Gipsum 6 Inchi Buah - - - - - - 37,500 - - - -
128 Glibenclamide Tab Tablet 735 - 735 - - 735 720 - - - 529,200
129 Gliseril Guaiakolat Tab 100 mg/ Guafenisine Tablet 3,084 100 3,184 800 2,384 1,000 132 13,200 105,600 - 314,688

LPLPO/KAB MBD Page 103


1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
130 Glukosa Larutan Infus 5 % Steril Botol 20 - 20 - 20 - 6,900 - - 138,000 -
131 Glukosa Larutan Infus 10 % Steril Botol - - - - - - 6,840 - - - -
132 Glukosa Larutan Infus 40 % Steril Botol - - - - - - - - - -
133 Griseovulvin Tab 125 mg, Micronized Tablet 2,118 - 2,118 30 - 2,088 242 - 7,260 - 505,296
134 Handscoen S Pcs - - - - - - -
135 Handscoen M Pcs - 200 200 200 - - - -
136 Handscoen L Pcs - 200 200 - - 200 - - - -
137 Handscoen No. 6 Pcs - - - - - - - - - -
138 Handscoen No.7 Pcs - 100 100 - - 100 6,985 698,500 - - 698,500
139 Handscoen No.7,5 Pcs - 100 100 - - 100 6,985 698,500 - - 698,500
140 Hidroklorotiasida ( HCT ) Tab 25 mg Tablet - - - - - - 194 - - - -
141 Hidrokortison Krim 2,5 mg Tube 96 - 96 10 - 86 2,846 - 28,460 - 244,756
142 Ibuprofen Suspensi Botol - 100 100 8 - 92 5,739 573,900 45,912 - 527,988
143 Ibuprofen Tab 200 mg Tablet - - - - - - - - - -
144 Ibuprofen Tab 400 mg Tablet - - - - - - - - - -
145 Infusion Set Anak Pcs 150 - 150 - 150 - 150 3,500 - - 525,000 -
146 Infusion Set Dewasa Pcs 40 - 40 - - 40 3,200 - - - 128,000
147 Isoniasid ( INH ) Tab 100 mg Tablet - - - - - - - - - -
148 Isoniasid ( INH ) Tab 300 mg Tablet - - - - - - 165 - - - -
149 Isosorbid Dinitrat Tab Sublingual 5 mg Tablet - - - - - - - - - -
150 Kalium Glukonat injeksi 10% (100mg/ml) Ampul - - - - - - 7,800 - - - -
151 Kalsium Laktat ( Kalk ) Tab 500 mg Tablet 1,520 - 1,520 100 - 1,420 62 - 6,200 - 88,040
152 Karbamasepin Tab 200 mg Tablet - - - - - - 241 - - - -
KAEN-3B Larutan infus (mengandung NaCl 1,75+KCL 1,5gr+ Na
153 Lactat 2,24 gr, Dextrose 27 gr) Botol - - - - - - 60 23,500 - - - -

154 Kapas Putih 1000 gr (Kapas Putih 1 Kg) Roll - 2 2 1 1 4 - - - -


155 Kantung Darah 250 cc Roll - - - - - - - - - -
156 Kapas Pembalut Absorben 250 Gram Roll - - - - - - 22,000 - - - -
157 Kapas Berlemak 500 mg Buah 6 - 6 1 5 16,500 - 16,500 - 82,500
158 Kasa Roll Panjang Besar 40x80 Cm Buah 2 4 6 1 - 5 105,000 420,000 105,000 - 525,000
159 Kasa Kompres 40/40 Steril Buah 350 - 350 25 - 325 1,600 - 40,000 - 520,000
160 Kasa Pembalut Hidrofil Steril 16 cm x 16 cm Buah - 10 10 - - 10 8,000 80,000 - - 80,000
161 Kasa Pembalut Hidrofil Supergrade 40 cm x 16 cm Buah - - - - - - 36,960 - - - -
162 Kasa Steril 10 cm x 10 cm Buah 3,200 - 3,200 - - 3,200 - - - -
163 Keterolac Inj 30 mg Ampul - - - - - - 50 1,265 - - - -
164 Ketokonazole Tab 200 mg Tablet 1,130 - 1,130 - - 1,130 311 - - - 351,430
165 Ketokonazole Krim Tube 50 - 50 5 - 45 2,893 - 14,465 - 130,185
166 Kinina Dihidroklorida ( Kina ) Inj 25 %-2ml Ampul - - - - - - 7,440 - - - -
167 Kuinin Sulfat Tab 222 mg ( H2O ) (Qunine 222 mg) Tablet 300 - 300 - - 300 799 - - - 239,700
168 Klorpromasin HCL Tab Salut 25 mg Tablet - - - - - - - - - -
169 Klorpromasin HCL Tab Salut 100 mg Tablet 200 - 200 - - 200 179 - - - 35,800
170 Klorpromasin Inj 25 mg/ml-1ml Ampul - - - - - - 1,550 - - - -
171 Klorpromasin Inj 5 mg/ ml-2ml Ampul - - - - - - - - - -
172 Kodein HCL ( Kodeina ) Tab 10 mg Tablet - - - - - - 600 - - - -
173 Klip Plastik 7 x 10 cm Pak - - - - - - 5,000 - - - -
174 Klip Plastik 8 x 5 cm Pak - - - - - - 5,000 - - - -
175 Kertas pulvis Pak - - - - - - 10,000 - - - -
176 Lancet blood Buah - - - - - - 623 - - - -
177 Lidokain Com, Inj Kombinasi Ampul 30 - 30 - - 30 1,433 - - - 42,990
178 Levofloksasin 500 mg Tablet - - - - - - 520 - - - -
179 Loratadine Tablet 10 mg Tablet - - - - - - 1,000 185 - - - -
180 Loperamide 10 mg Tablet - - - 1,000 - - - -
181 Maxiflow Baby (Masker Oksigen) Pcs - - - - - - 1,000 - - - -
182 Maxiflow Anak (Masker Oksigen) Pcs - - - - - - - - - -
183 Maxiflow Dewasa (Masker Oksigen) Pcs - - - - - - - - - -
184 Masker Botol 17 - 17 2 - 15 20 1,226 - 2,452 - 18,390
185 Masker Respirator N-95 Buah - - - - - - 100 - - - -
186 Methilprednisolon Tablet 4 mg Tablet - - - - - - 1,000 - - - -
187 Methilergometrin Maleat Inj 0,200 mg/ml-1ml Tablet - - - - - - 9,900 - - - -
188 Methilergometrin Maleat Tab salut 0,125 mg Tablet - - - - - - 185 - - - -
189 Meloxicam 7,5 mg Tablet - - - - - - - - - -
190 Meloxicam 15 mg Tablet - - - - - - 1,719 - - - -
191 Metformin HCL Tab 500 mg Tablet 1,140 - 1,140 - - 1,140 138 - - - 157,320
192 Metformin HCL Tab 850 mg Tablet - 500 500 - - 500 168 84,000 - - 84,000
193 Metoklopramide Tab 10 mg Tablet 1,800 - 1,800 - - 1,800 117 - - - 210,600
194 Metronidasol Infus 500 mg/100 ml Botol 12 24 36 - - 36 11,547 277,128 - - 415,692
195 Metronidasol Tab 250 mg Tablet - - - - - - 99 - - - -
196 Metronidasol Tab 500 mg Tablet - - - - - - 176 - - - -
197 Mikonazol Krim / Salf 2% ( Nitrat ) Tube - 24 24 - - 24 4,268 102,432 - - 102,432
198 Microlax Suppos Suppos - - - - - - - - - -
199 Mucus Extractor Buah - - - - - - - - - -

LPLPO/KAB MBD Page 104


1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
200 Natrium Diklofenak Tab 25 mg Tablet 2,940 - 2,940 - 2,940 163 - - - 479,220
201 Natrium Diklofenak Tab 50 mg Tablet 4,300 - 4,300 50 - 4,250 162 - 8,100 - 688,500
202 Natrium Klorida Larutan Infus 0,9% Steril Botol - - - - - - 6,410 - - - -
203 Nifedipin Tab 10 mg Tablet 90 90 30 - 60 219 - 6,570 - 13,140
204 Nistatin 100.000 IU/g Tab Vaginal Tablet - 100 100 - - 100 858 85,800 - - 85,800
205 Nistatin 500.000 IU/ Tab Salut Tablet - - - - - - 768 - - - -
206 NGT No. 6 Buah - - - - - - 22,000 - - - -
207 NGT.No. 8 Buah - - - - - - 22,000 - - - -
208 NGT.No.12 Buah - - - - - - 22,000 - - - -
209 NGT.No.14 Buah - - - - - - 22,000 - - - -
210 NGT.No.18 Buah - - - - - - 22,000 - - - -
211 Obat Batuk Hitam Botol 10 - 10 - - 10 200 2,670 - - - 26,700
212 Omeprasol Tab 20 mg Tablet 155 - 155 - 40 115 800 150 - - 6,000 17,250
213 Ondansetron Tablet 4 mg Tablet - - - - - - 1,090 - - - -
214 Obgyn Steril Handscoen Pcs - 100 100 - - 100 1,500 150,000 - - 150,000
215 Oralit/ Garam Oralit Saschet 1,700 - 1,700 - 1,700 - 1,000 296 - - 503,200 -
216 Objec Glass/Slide Pcs - - - - - - - - - -
217 Oxibiotic injeksi Vial - - - - - - - - - -
218 Oxitetrasikllin HCL Inj I.M 50mg/ml-10ml Vial - - - - - - - - - -
219 Oxitetrasikllin HCL Salep Kulit 3% Tube 2 - 2 - 2 - 1,259 - - 2,518 -
220 Oxitetrasikllin Salep Mata 1% Tube - - - - - - 2,600 - - - -
221 Oxitosin Inj 10 IU /ml-1ml (pitogin Injeksi) Ampul - - - - - - 3,020 - - - -
222 Oxyflow Baby Pcs - - - - - - - - - -
223 Oxyflow Anak Pcs - - - - - - - - - -
224 Oxyflow Dewasa Pcs - - - - - - - - - -
225 Pap Smer Kit S Pcs - - - - - - - - - -
226 Pap Smer Kit M Pcs - - - - - - -
227 Pap Smer Kit L Pcs - - - - - - -
228 Papaverin Inj 40mg/ml Ampul - - - - - - - - - -
229 Papaverin Tab 40 mg Tablet - - - - - - - - - -
230 Parasetamol Sirup 120 mg/ml Botol 82 - 82 13 - 69 200 1,252 - 16,276 - 86,388
231 Parasetamol Tab 500 mg Tablet 1,405 300 1,705 800 - 905 6,000 66 19,800 52,800 - 59,730
232 Pirantel Pamoat ( Pirantel ) Tab 125 mg Tablet 132 - 132 - - 132 334 - - - 44,088
233 Piridoksin HCL ( Vit B6 ) Tab 10 mg Tablet - 500 500 - - 500 154 77,000 - - 77,000
234 Piroxicam Tab 10 mg Tablet 3,625 - 3,625 - - 3,625 334 - - - 1,210,750
235 Piroxicam Tab 20 mg Tablet - - - - - - 244 - - - -
236 Plester 5 Yard x 2 Inch Buah - 24 24 - - 24 - - - -
237 Pirasetam Tab 400 mg Tablet - - - - - - - - - -
238 Pirasinamida Tab 500 mg Tablet - - - - - - - - - -
239 Prednison Tab 5 mg Tablet - 500 500 20 - 480 500 91 45,500 1,820 - 43,680
240 Primakuin Tab 15 mg Tablet 2,000 - 2,000 - - 2,000 175 - - - 350,000
241 Primperan Injeksi Vial - - - - - - - - - -
242 Prokain Penisillin G Inj 3 Juta IU Ampul - - - - - - 22,880 - - - -
243 Propanolol HCL ( Propanolol ) Tab 40 mg Tablet - - - - - - 64 - - - -
244 Ranitidin Inj 25 mg/ml Vial - - - - - - 1,540 - - - -
245 Ranitidin Tab 150 mg Tablet 4,800 - 4,800 50 - 4,750 121 - 6,050 - 574,750
246 Retinol ( Vit A ) Kapsul Lunak 100.000 IU Kapsul 100 - 100 - - 100 500 355 - - - 35,500
247 Retinol ( Vit A ) Kapsul Lunak 200.000 IU Kapsul 746 100 846 4 - 842 648 64,800 2,592 - 545,616
248 Retinol ( Vit A ) Kapsul Lunak 50.000 IU Kapsul - - - - - - - - - -
249 Ringer Laktat Larutan Infus Steril Botol - 60 60 8 - 52 7,150 429,000 57,200 - 371,800
250 Rivanol Larutan (Etakridin ) 300 ml Botol - - - - - - 7,200 - - - -
251 Salbutamol Tab 2 mg Tablet - - - - - - - - - -
252 Salbutamol Tab 4 mg - - - 81 - - - -
253 Sefadroxil syrup 125mg/ml Botol - - - - - - 200 4,581 - - - -
254 Sefadroxil Kapsul 250 mg Kapsul - - - - - - 1,000 - - - -
255 Sefadroxil Kapsul 500 mg Kapsul - - - - - - 587 - - - -
256 Setirizine Tab 10 mg Tablet 500 - 500 30 - 470 103 - 3,090 - 48,410
257 Setirizine Suspensi Botol - - - - - 100 3,192 - - - -
258 Semen Seng Fosfat Serbuk dan Cairan Botol - - - - - - - - - -
259 Sianokobalamin (Vit B12 ) Inj 500 mcg / ml-1ml vial 100 - 100 - - 100 1,335 - - - 133,500
260 Sianokobalamin ( Vit B12 ) Tab 50 mg Tablet 6,094 - 6,094 - - 6,094 53 - - - 322,982
261 Seftriakson Inj 1 g/Vial vial - - - - - - 5,143 - - - -
262 Sefotaxim Inj 1 g/ Vial vial - - - - - - 7,700 - - - -
263 Simetidin Tab 200 mg Tablet - - - - - - - - - -
264 Simvastatin 5 mg Tablet - - - - - - -
265 Simvastatin Tab 10 mg Tablet - - - - - - 500 110 - - - -
266 Siprofloxasin Tab 250 mg Tablet - - - - - - - - - -
267 Siprofloxasin Tab 500 mg Tablet 470 - 470 - - 470 305 - - - 143,350
268 Scabimite Krim Tube - 10 10 1 - 9 37,525 375,250 37,525 - 337,725
269 Sofratule (Daryantull) Pcs - - - - - - - - - -
270 Sohobion Injeksi Ampul - - - - - - 4,740 - - - -

LPLPO/KAB MBD Page 105


1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
271 Silk Benang Bedah Sutera + Jarum No.2/0 75 cm Pcs - 36 36 - - 36 4,583 164,988 - - 164,988
272 Silk Benang Bedah Sutera + Jarum No.3/0 75 cm pcs - 36 36 - - 36 4,583 164,988 - - 164,988
273 Sofband Gips 6 Inch roll - - - - - - 37,500 - - - -
274 Sofband Gips 4 inch Roll - - - - - - 28,500 - - - -
275 Stik Glukosa Easy Touch Buah - - - - - - - - - -
276 Stik As. Urat Easy Touch Buah - - - - - - - - - -
277 Stik Kolesterol Easy Touch Buah - - - - - - - - - -
278 Tetrasiklin Kapsul 250 mg Kapsul - - - - - - 193 - - - -
279 Tetrasiklin Kapsul 500 mg Kapsul 1,750 - 1,750 - - 1,750 348 - - - 609,000
280 Terramycin Injeksi Vial - 10 10 - - 10 15,300 153,000 - - 153,000
281 Thiamin HCL / Monoitrat (Vit B1) Tab 50 mg Tablet 209 - 209 - - 209 1,000 98 - - - 20,482
282 Thiamin HCL ( Vit B1 ) Inj 100 mg/ml-1ml Vial - - - - - - 50 - - - -
283 Tranfusi Set (Blood Set) Pcs - - - - - - 3,600 - - - -
284 Tramadol injeksi Ampul - - - - - - - - - -
285 Urine Bag pcs 15 10 25 - - 25 3,000 30,000 - - 75,000
286 Ultra Sonic Gell Botol - - - - - - 12,854 - - - -
287 Under Pad 60 cm x 90 Steril With SAP Pcs - - - - - - - - - -
288 Ventolin injeksi (inhaler) Vial - - - - - - 50 - - - -
289 Ventolin Nebulizer Ampul - - - - - - 10 28,220 - - - -
290 Vaksin Verorab (Anti Rabies) vial - - - - - - 267,000 - - - -
291 Vitamin B Complex Tab Tablet - - - - - - 2,000 147 - - - -
292 Vitamin B Complex Inj Ampul 10 - 10 - - 10 100 11,273 - - - 112,730
293 Wing Needlee No. 23 pcs - - - - - - 200 14,000 - - - -
294 Wing Needlee No. 25 Pcs - - - - - - 200 14,000 - - - -
295 Wing Needlee No. 27 Pcs - - - - - - 200 14,000 - - - -
296 Yodium Povidon Larutan 10% - 60 ml Botol 5 - 5 - 5 - 20 7,532 - - 37,660 -
297 Yodium Povidon Larutan 10% - 300 ml Botol - - - - - - - - - -
298 Yodium Povidon Larutan 10% - 1000 ml Botol 4 - 4 1 - 3 10 79,650 - 79,650 - 238,950
299 Zinc Tablet dispersible 20 mg Tablet 4,670 - 4,670 100 - 4,570 1,000 658 - 65,800 - 3,007,060
TOTAL HARGA 8,571,614 1,032,855 1,466,753 34,238,582

DAFTAR TAMBAHAN LPLPO PUSKESMAS MARSELA DESEMBER 2019


1

UMUM
JUMLAH KUNJUNGAN RESEP ASKES JUMLAH
BAYAR TIDAK BAYAR
0 126 105 231 5 JANUARI 2019

Mengetahui/Menyetujui; Yang Menyerahkan; Yang Meminta; Yang Menerima;


Kepala Dinas Kesehatan Kabupaten Petugas Gudang Farmasi, Pimpinan Puskesmas, Petugas Puskesmas,
Maluku Barat Daya,

ROBERT DJ. LEWIER AGUNG PRATOYO, S.Farm., Apt


NIP. NIP. NIP. 19740711 1997 1004 NRPK. 25.6.05.04262

LPLPO/KAB MBD Page 106


Kode Puskesmas :
Puskesmas :
Kecamatan : BULAN ; November
Puskesmas Pembantu yg Ada ……………. TAHUN : 2019
Kabupaten : MALUKU BARAT DAYA
Provinsi : MALUKU
LAPORAN PEMAKAIAN DAN LEMBAR PERMINTAAN OBAT (LPLPO)

Total Harga Total Harga Total Harga


KODE/N STOK Kadaluwarsa/R STOK Harga Kadaluwarsa/R
NAMA OBAT dan PERBEKALAN KESEHATAN SATUAN PENERIMAAN PERSEDIAAN PEMAKAIAN SISA STOK PERMINTAAN Penerimaan Pemakaian Sisa Stock KET
O. URT AWAL usak APT Satuan (Rp) usak (Rp)
(Rp) (Rp) (Rp)

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
1 Alat Suntik Sekali Pakai 1 CC Buah - - - - - - - 1,100 - - - -
2 Alat Suntik Sekali Pakai 2,5 CC Buah - - - - - - 1,750 - - - -
3 Alat Suntik Sekali Pakai 3 CC Buah - - - - - - 500 779 - - - -
4 Alat Suntik Sekali Pakai 5 CC Buah 800 - 800 25 - 775 968 - 24,200 - 750,200
5 Alat Suntik Sekali Pakai 10 CC Buah 185 - 185 - - 185 1,375 - - - 254,375
6 Alat Suntik Sekali Pakai 20 CC Buah - - - - - - 1,500 - - - -
7 Abocath ( I.V. Catheter) No. 18 Buah - - - - - - 50 3,800 - - - -
8 Abocath (I.V.Catheter) No.20 Buah - - - - - - 50 3,800 - - - -
9 Abocath (I.V.Catheter) No.22 Buah - - - - - - 50 3,800 - - - -
10 Abocath (I.V.Catheter) No.24 Buah - - - - - - 50 3,800 - - - -
11 Abocath (I.V.Catheter) No.26 Buah - - - - - - 50 4,100 - - - -
12 Albendasol Tab 400 mg Tablet - - - - - - 492 - - - -
13 Alkohol 70 % 1000 ml ( Etanol ) Botol 31 - 31 - - 31 25,000 - - - 775,000
14 Alkohol 70 % 100 ml ( Etanol ) Botol - - - - - - 50 - - - -
15 Allopurinol Tab 100 mg Tablet 720 - 720 50 - 670 - - - -
16 Allopurinol Tab 300 mg Tablet - - - - - - 108 - - - -
17 Ambroxol sirup 15 mg/ml Botol - - - - - - 200 6,095 - - - -
18 Ambroxol Tab 30 mg Tablet 1,992 - 1,992 420 - 1,572 1,500 201 - 84,420 - 315,972
19 Aminofillin inj 24 mg/ml-10 ml Ampul - - - - - - 50 3,280 - - - -
20 Aminofilin Tab 200 mg Tablet 500 - 500 - - 500 107 - - - 53,500
21 Amoxicillin Kaplet 250 mg Kaplet 3,660 - 3,660 540 - 3,120 3,000 212 - 114,480 - 661,440
22 Amoxicillin Kapsul 500 mg Kapsul - - - - - - 245 - - - -
23 Amoxicillin Sirup Kering 125 mg/ 5 ml Botol - - - - - - 100 2,790 - - - -
24 Ampisillin Kaplet 250 mg Kaplet - - - - - - - - - -
25 Ampisillin Kaplet 500 mg Kaplet 850 - 850 50 - 800 1,000 450 - 22,500 - 360,000
26 Ampisillin Serbuk Inj 1.m/ i.v 1000 mg/ml Vial - - - - - - 100 10,296 - - - -
27 Ampisillin sirup Kering 125 mg/ 5 ml Botol - - - - - - - - - -
28 Amlodipin 5 mg tablet tablet 2,685 - 2,685 20 - 2,665 500 99 - 1,980 - 263,835
29 Amlodipin 10 mg Tablet - - - - - - 83 - - - -
30 Anvomer B6 Tab Tablet - - - - - - 3,987 - - - -
31 Antasida Doen Tab Kombinasi Tablet 4,050 - 4,050 312 - 3,738 58 - 18,096 - 216,804
32 Antasida Doen II Suspensi Botol - - - - - - 200 2,257 - - - -

33 Anti Fungi Doen Kombinasi (Asam Bensoat 3%+As.Salisilat 6% 189 - 189 - - 189 5,620 - - - 1,062,180
(Whitefield) Tube
34 Anti Malaria Doen Kombinasi (DHP) Tablet - - - - - - 2,070 - - - -
35 Aquadest Steril (Air Untuk Injeksi Ampul 25 ml) Ampul - - - - - - 1,000 2,798 - - - -
36 Artemeter injeksi 80 mg/ml Ampul - - - - - - 26,600 - - - -
37 Artesunat Injeksi Ampul - - - - - - 48,750 - - - -
38 Asam Salisilat 2% + Belerang Endap 4% ( salf 2-4 ) Tube - - - - - - 3,274 - - - -
39 Asam Askorbat ( Vit C ) Tab 50 mg Tablet 1,610 - 1,610 180 - 1,430 131 - 23,580 - 187,330
40 Asam Folat Tab 1 mg Tablet 1,800 - 1,800 - - 1,800 88 - - - 158,400
41 Asam Mefenamat Kapsul 250 mg Kaplet - - - - - - - - - -
42 Asam Mefenamat Kaplet 500 mg Kaplet 420 - 420 270 - 150 1,500 195 - 52,650 - 29,250
43 Asam Traneksamat injeksi 100 mg/ml Ampul - - - - - - 50 2,798 - - - -
44 Aspar - K Tab Tablet - - - - - - 4,312 - - - -
45 Atropina Sulfat Inj 0,25 mg/ml-1ml Ampul - - - - - - 50 1,914 - - - -
46 ATS Injeksi 1500 IU Ampul - - - - - - 43,183 - - - -

LPLPO/KAB MBD Page 107


1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
47 Asiklovir Krim 5 % Tube - - - - - - 50 4,383 - - - -
48 Asiklovir Tab 200 mg Tablet - - - - - - 236 - - - -
49 Asiklovir Tab 400 mg Tablet 450 - 450 40 - 410 400 414 - 16,560 - 169,740
50 Bedak Salysil Serbuk 2 % Dus - - - - - - 50 1,142 - - - -
51 Benzatin Bensil Penisillin 1,2 Juta IU Vial - - - - - - 50 - - - -

52 Bessi II Sulfat Tab Kombinasi : Besi II sulfat 7H2O 200 mg, Asam Tablet 1,790 - 1,790 30 - 1,760 445 - 13,350 - 783,200
Folat 0,25 mg (Fe = Tambah Darah)
53 Betametason 0,1% Krim Tube 35 - 35 5 - 30 1,520 - 7,600 - 45,600
54 Bisoprolol tab Tablet - - - - - - - - - -
55 Bioplasenton gel Tube - - - - - - 50 17,928 - - - -
56 Buscopan Injeksi Ampul - - - - - - 50 - - - -
57 Bufacetin Salep Kulit Krim Tube - - - - - - 4,024 - - - -
58 Captopril Tablet 12,5 mg Tablet 1,827 - 1,827 100 - 1,727 87 - 8,700 - 150,249
59 Captopril Tablet 25 mg Tablet - - - - - - 86 - - - -
60 Catgut Chromic + Jarum No. 2/0 75 cm Pcs - - - - - - 10 5,583 - - - -
61 Catgut Chromic + Jarum No. 3/0 75 cm Pcs - - - - - - 10 5,583 - - - -
62 Catgut Plain + Jarum No.2/0 75 cm Pcs - - - - - - 10 5,583 - - - -
63 Catgut Plain + Jarum No. 3/0 75 cm Pcs - - - - - - 10 5,583 - - - -
64 Catapres Injeksi Ampul - - - - - - 10 97,220 - - - -
65 Chloramfeniramine Maleat (Ctm) Tablet 420 - 420 409 - 11 2,000 26 - 10,634 - 286
66 Chloramfenikol Kapsul 250 mg Kapsul 3,850 - 3,850 - - 3,850 357 - - - 1,374,450
67 Chloramfenikol Kapsul 500 mg Kapsul - - - - - - - - - -
68 Chloramfenikol Salf Mata 1% Tube - - - - - - 30 2,160 - - - -
69 Chloramfenikol Suspensi 125 mg/5 ml Botol 72 - 72 - - 72 - - - -
70 Chloramfenikol Tetes Telinga 3 % Botol - - - - - - 10 2,590 - - - -
71 Chloramfenikol Salep Kulit 2 % Tube - - - - - - 4,042 - - - -
72 Clindamiciyn 150 mg Kapsul 500 - 500 - - 500 720 - - - 360,000
73 Clindamicin 300 mg Kapsul - - - - - - 893 - - - -
74 Cotrimoxasol Suspensi Botol - - - - - - 2,155 - - - -

75 Cotrimoxasol Tab kombinasi : Sulfametoksazole 400mg , Tablet - - - - - - 132 - - - -


Trimetroprim 80 mg
76 Dexamethason Inj 5 mg/ml-1 ml Vial - - - - - - 100 1,378 - - - -
77 Dexamethason Tab 0,5 mg Tablet - - - - - - 1,000 37 - - - -
78 Diazepam Inj 5mg/ml-2ml Ampul 30 - 30 - - 30 2,150 - - - 64,500
79 Diazepam Tab 2 mg Tablet - - - - - - 86 - - - -
80 Diazepam Tab 5 mg Tablet 226 - 226 - - 226 115 - - - 25,990
81 Difenhidramin HCL Inj 10 mg/ml-1 ml Vial - - - - - - 50 1,373 - - - -
82 Digoxin Tab 0,25 mg Tablet - - - - - - 100 104 - - - -
83 Dimenhidrinat Tablet 50 mg Tablet - - - - - - - - - -
84 Doksisiklik Kapsul 100 mg Kapsul - - - - - - 264 - - - -
85 Domperidon Tab 10 mg Tablet 813 - 813 - - 813 190 - - - 154,470
86 Dulcolax Tab Tablet - - - - - - 100 166 - - - -
87 Dulcolax Suppos Suppos - - - - - - 50 36,200 - - - -
88 Diltiasem HCL Tab 30 mg Tablet - - - - - - 153 - - - -
89 Efedrin HCL ( Efedrina ) Tab 25 mg Tablet - - - - - - 200 - - - -
90 Elastic Verband 4 Inchi Buah 10 - 10 - - 10 20 30,250 - - - 302,500
91 Elastic Verband 6 Inchi Buah - - - - - - 10 - - - -
92 Erlamycetin Tetes Telinga Botol - - - - - - 20 5,658 - - - -
93 Epinefrin HCL / Bitartrat ( Adrenalin ) Inj. 0,1%-1ml Ampul - - - - - - 50 2,486 - - - -
94 ErLamycetin Tetes Mata Botol 1 - 1 - - 1 10 8,183 - - - 8,183
95 Eritr0misin Kapsul 250 mg Kapsul - - - - - - 693 - - - -
96 Eritromisin Kapsul 500 mg Kapsul 170 - 170 - - 170 704 - - - 119,680
97 Eritromisin Sirup 200 mg/5 ml Botol 78 - 78 - - 78 6,788 - - - 529,464
98 Etil Klorida Spray Botol - - - - - - - - - -
99 Etambutol HCL ( Etambutol ) Tab 250 mg Tablet - - - - - - 100 - - - -
100 Extension Tube Pcs - - - - - - - - - -
101 Eugenol cairan Botol - - - - - - 20 20,000 - - - -
102 Fenobarbital Inj 50 mg/ml-2ml vial - - - - - - 20 2,325 - - - -
103 Fenobarbital Tab 30 mg Tablet - - - - - - 243 - - - -

LPLPO/KAB MBD Page 108


1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
104 Fenol Gliseron tetes telinga 10 % Botol 3 - 3 - - 3 10 2,590 - - - 7,770
105 Fitomenadion ( Vit K1 ) Inj 10 mg/ml-1ml Vial - - - - - - 50 4,438 - - - -
106 Fitomenadion ( Vit K1 ) Tab Salut 10 mg Tablet 5,105 - 5,105 - - 5,105 890 - - - 4,543,450
107 Foley Catheter T. 6 Botol - - - - - - 10 30,000 - - - -
108 Foley Catheter T. 8 Buah - - - - - - 10 30,000 - - - -
109 Foley Catheter T.10 Buah - - - - - - 10 30,000 - - - -
110 Foley Catheter T.12 Buah - - - - - - 10 8,000 - - - -
111 Foley Catheter T.14 Buah - - - - - - 10 8,000 - - - -
112 Foley Catheter T. 16 Buah - - - - - - 10 8,000 - - - -
113 Foley Catheter T.18 Buah - - - - - - 10 8,000 - - - -
114 Foley Catheter T. 20 Buah - - - - - - 10 8,000 - - - -
115 Foley Catheter T. 22 Buah - - - - - - 10 8,000 - - - -
116 Foley Catheter T. 24 Buah - - - - - - 10 8,000 - - - -
117 Flagystatin Tablet Vagina Tablet - - - - - - 30 29,520 - - - -
118 Furosemida Inj i.v i.m 10 mg/ml Vial - - - - - - 50 1,850 - - - -
119 Furosemida Tab 40 mg Tablet 270 - 270 - - 270 88 - - - 23,760
120 Formalin Cairan Botol - - - - - - 10 - - - -
121 Gentamisin Inj 80 mg/ 2ml Ampul - - - - - - 30 3,854 - - - -
122 Gentamisin Salf Kulit 0,1 % Tube 10 - 10 - - 10 - - - -
123 Gentamisin Slufat Tetes Mata 0,3 % Botol - - - - - - 10 5,020 - - - -
124 Glimepride Tab 4 mg Tablet - - - - - - 1,000 273 - - - -
125 Gentian Violet Larutan 1 % Botol 15 - 15 - - 15 5,200 - - - 78,000
126 Gipsonal Gipsum 4 Inchi Buah - - - - - - 10 28,500 - - - -
127 Gipsonal Gipsum 6 Inchi Buah - - - - - - 10 37,500 - - - -
128 Glibenclamide Tab Tablet 735 - 735 - - 735 720 - - - 529,200
129 Gliseril Guaiakolat Tab 100 mg/ Guafenisine Tablet 3,527 - 3,527 443 - 3,084 132 - 58,476 - 407,088
130 Glukosa Larutan Infus 5 % Steril Botol 20 - 20 - - 20 72 6,900 - - - 138,000
131 Glukosa Larutan Infus 10 % Steril Botol - - - - - - 6,840 - - - -
132 Glukosa Larutan Infus 40 % Steril Botol - - - - - - - - - -
133 Griseovulvin Tab 125 mg, Micronized Tablet 2,118 - 2,118 - - 2,118 242 - - - 512,556
134 Handscoen S Pcs - - - - - - -
135 Handscoen M Pcs - - - 200 - - - -
136 Handscoen L Pcs - - - - - - 300 - - - -
137 Handscoen No. 6 Pcs - - - - - - - - - -
138 Handscoen No.7 Pcs - - - - - - 100 6,985 - - - -
139 Handscoen No.7,5 Pcs - - - - - - 100 6,985 - - - -
140 Hidroklorotiasida ( HCT ) Tab 25 mg Tablet - - - - - - 194 - - - -
141 Hidrokortison Krim 2,5 mg Tube 96 - 96 - - 96 2,846 - - - 273,216
142 Ibuprofen Suspensi Botol - - - - - - 100 5,739 - - - -
143 Ibuprofen Tab 200 mg Tablet - - - - - - - - - -
144 Ibuprofen Tab 400 mg Tablet - - - - - - 1,000 - - - -
145 Infusion Set Anak Pcs 150 - 150 - - 150 3,500 - - - 525,000
146 Infusion Set Dewasa Pcs 40 - 40 - - 40 3,200 - - - 128,000
147 Isoniasid ( INH ) Tab 100 mg Tablet - - - - - - - - - -
148 Isoniasid ( INH ) Tab 300 mg Tablet - - - - - - 165 - - - -
149 Isosorbid Dinitrat Tab Sublingual 5 mg Tablet - - - - - - 100 - - - -
150 Kalium Glukonat injeksi 10% (100mg/ml) Ampul - - - - - - 50 7,800 - - - -
151 Kalsium Laktat ( Kalk ) Tab 500 mg Tablet 1,520 - 1,520 - - 1,520 62 - - - 94,240
152 Karbamasepin Tab 200 mg Tablet - - - - - - 241 - - - -
KAEN-3B Larutan infus (mengandung NaCl 1,75+KCL 1,5gr+ Na
153 Lactat 2,24 gr, Dextrose 27 gr) Botol - - - - - - 48 23,500 - - - -

154 Kapas Putih 1000 gr (Kapas Putih 1 Kg) Roll - - - - - - 2 - - - -


155 Kantung Darah 250 cc Roll - - - - - - - - - -
156 Kapas Pembalut Absorben 250 Gram Roll - - - - - - 10 22,000 - - - -
157 Kapas Berlemak 500 mg Buah 6 - 6 - - 6 16,500 - - - 99,000
158 Kasa Roll Panjang Besar 40x80 Cm Buah 2 - 2 - - 2 4 105,000 - - - 210,000
159 Kasa Kompres 40/40 Steril Buah 350 - 350 - - 350 1,600 - - - 560,000
160 Kasa Pembalut Hidrofil Steril 16 cm x 16 cm Buah - - - - - - 8,000 - - - -
161 Kasa Pembalut Hidrofil Supergrade 40 cm x 16 cm Buah - - - - - - 36,960 - - - -

LPLPO/KAB MBD Page 109


1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
162 Kasa Steril 10 cm x 10 cm Buah 3,200 - 3,200 - - 3,200 - - - -
163 Keterolac Inj 30 mg Ampul - - - - - - 50 1,265 - - - -
164 Ketokonazole Tab 200 mg Tablet 1,130 - 1,130 - - 1,130 311 - - - 351,430
165 Ketokonazole Krim Tube 50 - 50 - - 50 2,893 - - - 144,650
166 Kinina Dihidroklorida ( Kina ) Inj 25 %-2ml Ampul - - - - - - 7,440 - - - -
167 Kuinin Sulfat Tab 222 mg ( H2O ) (Qunine 222 mg) Tablet 300 - 300 - - 300 799 - - - 239,700
168 Klorpromasin HCL Tab Salut 25 mg Tablet - - - - - - - - - -
169 Klorpromasin HCL Tab Salut 100 mg Tablet 200 - 200 - - 200 179 - - - 35,800
170 Klorpromasin Inj 25 mg/ml-1ml Ampul - - - - - - 1,550 - - - -
171 Klorpromasin Inj 5 mg/ ml-2ml Ampul - - - - - - - - - -
172 Kodein HCL ( Kodeina ) Tab 10 mg Tablet - - - - - - 600 - - - -
173 Klip Plastik 7 x 10 cm Pak - - - - - - 2,000 - - - -
174 Klip Plastik 8 x 5 cm Pak - - - - - - 2,000 - - - -
175 Kertas pulvis Pak - - - - - - 2,000 - - - -
176 Lancet blood Buah - - - - - - 623 - - - -
177 Lidokain Com, Inj Kombinasi Ampul 30 - 30 - - 30 1,433 - - - 42,990
178 Levofloksasin 500 mg Tablet - - - - - - 520 - - - -
179 Loratadine Tablet 10 mg Tablet - - - - - - 400 185 - - - -
180 Loperamide 10 mg Tablet - - - 400 - - - -
181 Maxiflow Baby (Masker Oksigen) Pcs - - - - - - - - - -
182 Maxiflow Anak (Masker Oksigen) Pcs - - - - - - - - - -
183 Maxiflow Dewasa (Masker Oksigen) Pcs - - - - - - - - - -
184 Masker Botol 17 - 17 - - 17 1,226 - - - 20,842
185 Masker Respirator N-95 Buah - - - - - - - - - -
186 Methilprednisolon Tablet 4 mg Tablet - - - - - - 1,000 - - - -
187 Methilergometrin Maleat Inj 0,200 mg/ml-1ml Tablet - - - - - - 9,900 - - - -
188 Methilergometrin Maleat Tab salut 0,125 mg Tablet - - - - - - 185 - - - -
189 Meloxicam 7,5 mg Tablet - - - - - - - - - -
190 Meloxicam 15 mg Tablet - - - - - - 1,719 - - - -
191 Metformin HCL Tab 500 mg Tablet 1,210 - 1,210 70 - 1,140 138 - 9,660 - 157,320
192 Metformin HCL Tab 850 mg Tablet - - - - - - 168 - - - -
193 Metoklopramide Tab 10 mg Tablet 1,800 - 1,800 - - 1,800 117 - - - 210,600
194 Metronidasol Infus 500 mg/100 ml Botol 12 - 12 - - 12 20 11,547 - - - 138,564
195 Metronidasol Tab 250 mg Tablet - - - - - - 99 - - - -
196 Metronidasol Tab 500 mg Tablet - - - - - - 176 - - - -
197 Mikonazol Krim / Salf 2% ( Nitrat ) Tube - - - - - - 4,268 - - - -
198 Microlax Suppos Suppos - - - - - - - - - -
199 Mucus Extractor Buah - - - - - - - - - -
200 Natrium Diklofenak Tab 25 mg Tablet 2,940 - 2,940 - - 2,940 163 - - - 479,220
201 Natrium Diklofenak Tab 50 mg Tablet 4,300 - 4,300 - - 4,300 162 - - - 696,600
202 Natrium Klorida Larutan Infus 0,9% Steril Botol - - - - - - 40 6,410 - - - -
203 Nifedipin Tab 10 mg Tablet 90 - 90 - - 90 219 - - - 19,710
204 Nistatin 100.000 IU/g Tab Vaginal Tablet - - - - - - 100 858 - - - -
205 Nistatin 500.000 IU/ Tab Salut Tablet - - - - - - 768 - - - -
206 NGT No. 6 Buah - - - - - - 22,000 - - - -
207 NGT.No. 8 Buah - - - - - - 22,000 - - - -
208 NGT.No.12 Buah - - - - - - 22,000 - - - -
209 NGT.No.14 Buah - - - - - - 22,000 - - - -
210 NGT.No.18 Buah - - - - - - 22,000 - - - -
211 Obat Batuk Hitam Botol 10 - 10 - - 10 50 2,670 - - - 26,700
212 Omeprasol Tab 20 mg Tablet 155 - 155 - - 155 150 - - - 23,250
213 Ondansetron Tablet 4 mg Tablet - - - - - - 1,090 - - - -
214 Obgyn Steril Handscoen Pcs - - - - - - 100 1,500 - - - -
215 Oralit/ Garam Oralit Saschet 1,700 - 1,700 - - 1,700 296 - - - 503,200
216 Objec Glass/Slide Pcs - - - - - - 100 - - - -
217 Oxibiotic injeksi Vial - - - - - - 50 - - - -
218 Oxitetrasikllin HCL Inj I.M 50mg/ml-10ml Vial - - - - - - - - - -
219 Oxitetrasikllin HCL Salep Kulit 3% Tube 2 - 2 - - 2 1,259 - - - 2,518
220 Oxitetrasikllin Salep Mata 1% Tube - - - - - - 2,600 - - - -

LPLPO/KAB MBD Page 110


1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
221 Oxitosin Inj 10 IU /ml-1ml (pitogin Injeksi) Ampul - - - - - - 3,020 - - - -
222 Oxyflow Baby Pcs - - - - - - 100 - - - -
223 Oxyflow Anak Pcs - - - - - - - - - -
224 Oxyflow Dewasa Pcs - - - - - - - - - -
225 Pap Smer Kit S Pcs - - - - - - - - - -
226 Pap Smer Kit M Pcs - - - - - - -
227 Pap Smer Kit L Pcs - - - - - - -
228 Papaverin Inj 40mg/ml Ampul - - - - - - - - - -
229 Papaverin Tab 40 mg Tablet - - - - - - - - - -
230 Parasetamol Sirup 120 mg/ml Botol 82 - 82 - - 82 1,252 - - - 102,664
231 Parasetamol Tab 500 mg Tablet 1,405 - 1,405 - - 1,405 66 - - - 92,730
232 Pirantel Pamoat ( Pirantel ) Tab 125 mg Tablet 132 - 132 - - 132 334 - - - 44,088
233 Piridoksin HCL ( Vit B6 ) Tab 10 mg Tablet - - - - - - 500 154 - - - -
234 Piroxicam Tab 10 mg Tablet 3,685 - 3,685 60 - 3,625 334 - 20,040 - 1,210,750
235 Piroxicam Tab 20 mg Tablet - - - - - - 244 - - - -
236 Plester 5 Yard x 2 Inch Buah - - - - - - 10 - - - -
237 Pirasetam Tab 400 mg Tablet - - - - - - - - - -
238 Pirasinamida Tab 500 mg Tablet - - - - - - - - - -
239 Prednison Tab 5 mg Tablet - - - - - - 500 91 - - - -
240 Primakuin Tab 15 mg Tablet 2,000 - 2,000 - - 2,000 175 - - - 350,000
241 Primperan Injeksi Vial - - - - - - - - - -
242 Prokain Penisillin G Inj 3 Juta IU Ampul - - - - - - 22,880 - - - -
243 Propanolol HCL ( Propanolol ) Tab 40 mg Tablet - - - - - - 64 - - - -
244 Ranitidin Inj 25 mg/ml Vial - - - - - - 50 1,540 - - - -
245 Ranitidin Tab 150 mg Tablet 4,800 - 4,800 - - 4,800 121 - - - 580,800
246 Retinol ( Vit A ) Kapsul Lunak 100.000 IU Kapsul 100 - 100 - - 100 200 355 - - - 35,500
247 Retinol ( Vit A ) Kapsul Lunak 200.000 IU Kapsul 750 - 750 4 - 746 648 - 2,592 - 483,408
248 Retinol ( Vit A ) Kapsul Lunak 50.000 IU Kapsul - - - - - - - - - -
249 Ringer Laktat Larutan Infus Steril Botol - - - - - - 72 7,150 - - - -
250 Rivanol Larutan (Etakridin ) 300 ml Botol - - - - - - 7,200 - - - -
251 Salbutamol Tab 2 mg Tablet - - - - - - 1,000 - - - -
252 Salbutamol Tab 4 mg - - - 500 81 - - - -
253 Sefadroxil syrup 125mg/ml Botol - - - - - - 200 4,581 - - - -
254 Sefadroxil Kapsul 250 mg Kapsul - - - - - - 1,000 - - - -
255 Sefadroxil Kapsul 500 mg Kapsul - - - - - - 1,000 587 - - - -
256 Setirizine Tab 10 mg Tablet - - - - - - 500 103 - - - -
257 Setirizine Suspensi Botol - - - - - - 50 3,192 - - - -
258 Semen Seng Fosfat Serbuk dan Cairan Botol - - - - - - - - - -
259 Sianokobalamin (Vit B12 ) Inj 500 mcg / ml-1ml vial 100 - 100 - - 100 100 1,335 - - - 133,500
260 Sianokobalamin ( Vit B12 ) Tab 50 mg Tablet 6,094 - 6,094 - - 6,094 53 - - - 322,982
261 Seftriakson Inj 1 g/Vial vial - - - - - - 100 5,143 - - - -
262 Sefotaxim Inj 1 g/ Vial vial - - - - - - 100 7,700 - - - -
263 Simetidin Tab 200 mg Tablet - - - - - - - - - -
264 Simvastatin 5 mg Tablet - - - 500 - - - -
265 Simvastatin Tab 10 mg Tablet - - - - - - 110 - - - -
266 Siprofloxasin Tab 250 mg Tablet - - - - - - - - - -
267 Siprofloxasin Tab 500 mg Tablet 470 - 470 - - 470 305 - - - 143,350
268 Scabimite Krim Tube - - - - - - 100 37,525 - - - -
269 Sofratule (Daryantull) Pcs - - - - - - - - - -
270 Sohobion Injeksi Ampul - - - - - - 100 4,740 - - - -
271 Silk Benang Bedah Sutera + Jarum No.2/0 75 cm Pcs - - - - - - 10 4,583 - - - -
272 Silk Benang Bedah Sutera + Jarum No.3/0 75 cm pcs - - - - - - 10 4,583 - - - -
273 Sofband Gips 6 Inch roll - - - - - - 2 37,500 - - - -
274 Sofband Gips 4 inch Roll - - - - - - 2 28,500 - - - -
275 Stik Glukosa Easy Touch Buah - - - - - - 150 - - - -
276 Stik As. Urat Easy Touch Buah - - - - - - 150 - - - -
277 Stik Kolesterol Easy Touch Buah - - - - - - 150 - - - -
278 Tetrasiklin Kapsul 250 mg Kapsul - - - - - - 193 - - - -
279 Tetrasiklin Kapsul 500 mg Kapsul 1,750 - 1,750 - - 1,750 348 - - - 609,000

LPLPO/KAB MBD Page 111


1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
280 Terramycin Injeksi Vial - - - - - - 15,300 - - - -
281 Thiamin HCL / Monoitrat (Vit B1) Tab 50 mg Tablet 579 - 579 370 - 209 1,000 98 - 36,260 - 20,482
282 Thiamin HCL ( Vit B1 ) Inj 100 mg/ml-1ml Vial - - - - - - - - - -
283 Tranfusi Set (Blood Set) Pcs - - - - - - 3,600 - - - -
284 Tramadol injeksi Ampul - - - - - - - - - -
285 Urine Bag pcs 18 - 18 3 - 15 10 3,000 - 9,000 - 45,000
286 Ultra Sonic Gell Botol - - - - - - 12,854 - - - -
287 Under Pad 60 cm x 90 Steril With SAP Pcs - - - - - - - - - -
288 Ventolin injeksi (inhaler) Vial - - - - - - 50 - - - -
289 Ventolin Nebulizer Ampul - - - - - - 50 28,220 - - - -
290 Vaksin Verorab (Anti Rabies) vial - - - - - - 10 267,000 - - - -
291 Vitamin B Complex Tab Tablet - - - - - - 1,500 147 - - - -
292 Vitamin B Complex Inj Ampul 10 - 10 - - 10 100 11,273 - - - 112,730
293 Wing Needlee No. 23 pcs - - - - - - 14,000 - - - -
294 Wing Needlee No. 25 Pcs - - - - - - 14,000 - - - -
295 Wing Needlee No. 27 Pcs - - - - - - 14,000 - - - -
296 Yodium Povidon Larutan 10% - 60 ml Botol 5 - 5 - - 5 7,532 - - - 37,660
297 Yodium Povidon Larutan 10% - 300 ml Botol - - - - - - - - - -
298 Yodium Povidon Larutan 10% - 1000 ml Botol 4 - 4 - - 4 79,650 - - - 318,600
299 Zinc Tablet dispersible 20 mg Tablet 4,670 - 4,670 - - 4,670 658 - - - 3,072,860
300 HbsAg 25
301 HCl Botol 2
TOTAL HARGA - 534,778 - 28,115,076

UMUM
JUMLAH KUNJUNGAN RESEP ASKES JUMLAH
BAYAR TIDAK BAYAR
0 0 …………………………………………. 2019

Mengetahui/Menyetujui; Yang Menyerahkan; Yang Meminta; Yang Menerima;


Kepala Dinas Kesehatan Kabupaten Petugas Gudang Farmasi, Pimpinan Puskesmas, Petugas Puskesmas,
Maluku Barat Daya,

NIP. NIP. NIP. NIP.

LPLPO/KAB MBD Page 112


Kode Puskesmas :
Puskesmas :
Kecamatan : BULAN ; Oktober
Puskesmas Pembantu yg Ada ……………. TAHUN : 2019
Kabupaten : MALUKU BARAT DAYA
Provinsi : MALUKU
LAPORAN PEMAKAIAN DAN LEMBAR PERMINTAAN OBAT (LPLPO)

Total Harga Total Harga Total Harga


KODE/N STOK Kadaluwarsa/R STOK Harga Kadaluwarsa/R
NAMA OBAT dan PERBEKALAN KESEHATAN SATUAN PENERIMAAN PERSEDIAAN PEMAKAIAN SISA STOK PERMINTAAN Penerimaan Pemakaian Sisa Stock KET
O. URT AWAL usak APT Satuan (Rp) usak (Rp)
(Rp) (Rp) (Rp)

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
1 Alat Suntik Sekali Pakai 1 CC Buah - - - - - - - 1,100 - - - -
2 Alat Suntik Sekali Pakai 2,5 CC Buah - - - - - - 1,750 - - - -
3 Alat Suntik Sekali Pakai 3 CC Buah - - - - - - 779 - - - -
4 Alat Suntik Sekali Pakai 5 CC Buah 800 - 800 - - 800 968 - - - 774,400
5 Alat Suntik Sekali Pakai 10 CC Buah 200 - 200 15 - 185 1,375 - 20,625 - 254,375
6 Alat Suntik Sekali Pakai 20 CC Buah - - - - - - 1,500 - - - -
7 Abocath ( I.V. Catheter) No. 18 Buah - - - - - - 3,800 - - - -
8 Abocath (I.V.Catheter) No.20 Buah - - - - - - 3,800 - - - -
9 Abocath (I.V.Catheter) No.22 Buah - - - - - - 3,800 - - - -
10 Abocath (I.V.Catheter) No.24 Buah - - - - - - 3,800 - - - -
11 Abocath (I.V.Catheter) No.26 Buah - - - - - - 4,100 - - - -
12 Albendasol Tab 400 mg Tablet - - - - - - 492 - - - -
13 Alkohol 70 % 1000 ml ( Etanol ) Botol 34 - 34 3 - 31 25,000 - 75,000 - 775,000
14 Alkohol 70 % 100 ml ( Etanol ) Botol - - - - - - - - - -
15 Allopurinol Tab 100 mg Tablet 970 - 970 250 - 720 - - - -
16 Allopurinol Tab 300 mg Tablet - - - - - - 108 - - - -
17 Ambroxol sirup 15 mg/ml Botol 1 - 1 1 - - 6,095 - 6,095 - -
18 Ambroxol Tab 30 mg Tablet 2,146 - 2,146 154 - 1,992 201 - 30,954 - 400,392
19 Aminofillin inj 24 mg/ml-10 ml Ampul - - - - - - 3,280 - - - -
20 Aminofilin Tab 200 mg Tablet 500 - 500 - - 500 107 - - - 53,500
21 Amoxicillin Kaplet 250 mg Kaplet 5,140 - 5,140 1,480 - 3,660 212 - 313,760 - 775,920
22 Amoxicillin Kapsul 500 mg Kapsul 254 - 254 254 - - 245 - 62,230 - -
23 Amoxicillin Sirup Kering 125 mg/ 5 ml Botol 11 - 11 11 - - 2,790 - 30,690 - -
24 Ampisillin Kaplet 250 mg Kaplet - - - - - - - - - -
25 Ampisillin Kaplet 500 mg Kaplet 1,350 - 1,350 500 - 850 450 - 225,000 - 382,500
26 Ampisillin Serbuk Inj 1.m/ i.v 1000 mg/ml Vial - - - - - - 10,296 - - - -
27 Ampisillin sirup Kering 125 mg/ 5 ml Botol - - - - - - - - - -
28 Amlodipin 5 mg tablet tablet 2,785 - 2,785 100 - 2,685 99 - 9,900 - 265,815
29 Amlodipin 10 mg Tablet - - - - - - 83 - - - -
30 Anvomer B6 Tab Tablet - - - - - - 3,987 - - - -
31 Antasida Doen Tab Kombinasi Tablet 4,600 - 4,600 550 - 4,050 58 - 31,900 - 234,900
32 Antasida Doen II Suspensi Botol - - - - - - 2,257 - - - -

33 Anti Fungi Doen Kombinasi (Asam Bensoat 3%+As.Salisilat 6% 189 - 189 - - 189 5,620 - - - 1,062,180
(Whitefield) Tube
34 Anti Malaria Doen Kombinasi (DHP) Tablet - - - - - - 2,070 - - - -
35 Aquadest Steril (Air Untuk Injeksi Ampul 25 ml) Ampul - - - - - - 2,798 - - - -
36 Artemeter injeksi 80 mg/ml Ampul - - - - - - 26,600 - - - -
37 Artesunat Injeksi Ampul - - - - - - 48,750 - - - -
38 Asam Salisilat 2% + Belerang Endap 4% ( salf 2-4 ) Tube - - - - - - 3,274 - - - -
39 Asam Askorbat ( Vit C ) Tab 50 mg Tablet 2,190 - 2,190 580 - 1,610 131 - 75,980 - 210,910
40 Asam Folat Tab 1 mg Tablet 2,000 - 2,000 200 - 1,800 88 - 17,600 - 158,400
41 Asam Mefenamat Kapsul 250 mg Kaplet - - - - - - - - - -
42 Asam Mefenamat Kaplet 500 mg Kaplet 2,048 - 2,048 1,628 - 420 195 - 317,460 - 81,900
43 Asam Traneksamat injeksi 100 mg/ml Ampul - - - - - - 2,798 - - - -
44 Aspar - K Tab Tablet - - - - - - 4,312 - - - -
45 Atropina Sulfat Inj 0,25 mg/ml-1ml Ampul - - - - - - 1,914 - - - -
46 ATS Injeksi 1500 IU Ampul - - - - - - 43,183 - - - -

LPLPO/KAB MBD Page 113


1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
47 Asiklovir Krim 5 % Tube - - - - - - 4,383 - - - -
48 Asiklovir Tab 200 mg Tablet - - - - - - 236 - - - -
49 Asiklovir Tab 400 mg Tablet 470 - 470 20 - 450 414 - 8,280 - 186,300
50 Bedak Salysil Serbuk 2 % Dus - - - - - - 1,142 - - - -
51 Benzatin Bensil Penisillin 1,2 Juta IU Vial - - - - - - - - - -

52 Bessi II Sulfat Tab Kombinasi : Besi II sulfat 7H2O 200 mg, Asam Tablet 2,160 - 2,160 370 - 1,790 445 - 164,650 - 796,550
Folat 0,25 mg (Fe = Tambah Darah)
53 Betametason 0,1% Krim Tube 39 - 39 4 - 35 1,520 - 6,080 - 53,200
54 Bisoprolol tab Tablet - - - - - - - - - -
55 Bioplasenton gel Tube - - - - - - 17,928 - - - -
56 Buscopan Injeksi Ampul - - - - - - - - - -
57 Bufacetin Salep Kulit Krim Tube - - - - - - 4,024 - - - -
58 Captopril Tablet 12,5 mg Tablet 1,997 - 1,997 170 - 1,827 87 - 14,790 - 158,949
59 Captopril Tablet 25 mg Tablet - - - - - - 86 - - - -
60 Catgut Chromic + Jarum No. 2/0 75 cm Pcs - - - - - - 5,583 - - - -
61 Catgut Chromic + Jarum No. 3/0 75 cm Pcs - - - - - - 5,583 - - - -
62 Catgut Plain + Jarum No.2/0 75 cm Pcs - - - - - - 5,583 - - - -
63 Catgut Plain + Jarum No. 3/0 75 cm Pcs - - - - - - 5,583 - - - -
64 Catapres Injeksi Ampul - - - - - - 97,220 - - - -
65 Chloramfeniramine Maleat (Ctm) Tablet 1,670 - 1,670 1,250 - 420 26 - 32,500 - 10,920
66 Chloramfenikol Kapsul 250 mg Kapsul 4,756 - 4,756 906 - 3,850 357 - 323,442 - 1,374,450
67 Chloramfenikol Kapsul 500 mg Kapsul - - - - - - - - - -
68 Chloramfenikol Salf Mata 1% Tube - - - - - - 2,160 - - - -
69 Chloramfenikol Suspensi 125 mg/5 ml Botol 92 - 92 20 - 72 - - - -
70 Chloramfenikol Tetes Telinga 3 % Botol - - - - - - 2,590 - - - -
71 Chloramfenikol Salep Kulit 2 % Tube - - - - - - 4,042 - - - -
72 Clindamiciyn 150 mg Kapsul 500 - 500 - - 500 720 - - - 360,000
73 Clindamicin 300 mg Kapsul - - - - - - 893 - - - -
74 Cotrimoxasol Suspensi Botol - - - - - - 2,155 - - - -

75 Cotrimoxasol Tab kombinasi : Sulfametoksazole 400mg , Tablet - - - - - - 132 - - - -


Trimetroprim 80 mg
76 Dexamethason Inj 5 mg/ml-1 ml Vial - - - - - - 1,378 - - - -
77 Dexamethason Tab 0,5 mg Tablet - - - - - - 37 - - - -
78 Diazepam Inj 5mg/ml-2ml Ampul 30 - 30 - - 30 2,150 - - - 64,500
79 Diazepam Tab 2 mg Tablet - - - - - - 86 - - - -
80 Diazepam Tab 5 mg Tablet 230 - 230 4 - 226 115 - 460 - 25,990
81 Difenhidramin HCL Inj 10 mg/ml-1 ml Vial - - - - - - 1,373 - - - -
82 Digoxin Tab 0,25 mg Tablet - - - - - - 104 - - - -
83 Dimenhidrinat Tablet 50 mg Tablet - - - - - - - - - -
84 Doksisiklik Kapsul 100 mg Kapsul - - - - - - 264 - - - -
85 Domperidon Tab 10 mg Tablet 814 - 814 1 - 813 190 - 190 - 154,470
86 Dulcolax Tab Tablet - - - - - - 166 - - - -
87 Dulcolax Suppos Suppos - - - - - - 36,200 - - - -
88 Diltiasem HCL Tab 30 mg Tablet - - - - - - 153 - - - -
89 Efedrin HCL ( Efedrina ) Tab 25 mg Tablet - - - - - - - - - -
90 Elastic Verband 4 Inchi Buah 10 - 10 - - 10 30,250 - - - 302,500
91 Elastic Verband 6 Inchi Buah - - - - - - - - - -
92 Erlamycetin Tetes Telinga Botol - - - - - - 5,658 - - - -
93 Epinefrin HCL / Bitartrat ( Adrenalin ) Inj. 0,1%-1ml Ampul - - - - - - 2,486 - - - -
94 ErLamycetin Tetes Mata Botol 1 - 1 - - 1 8,183 - - - 8,183
95 Eritr0misin Kapsul 250 mg Kapsul - - - - - - 693 - - - -
96 Eritromisin Kapsul 500 mg Kapsul 170 - 170 - - 170 704 - - - 119,680
97 Eritromisin Sirup 200 mg/5 ml Botol 88 - 88 10 - 78 6,788 - 67,880 - 529,464
98 Etil Klorida Spray Botol - - - - - - - - -
99 Etambutol HCL ( Etambutol ) Tab 250 mg Tablet - - - - - - - - - -
100 Extension Tube Pcs - - - - - - - - - -
101 Eugenol cairan Botol - - - - - - 20,000 - - - -
102 Fenobarbital Inj 50 mg/ml-2ml vial - - - - - - 2,325 - - - -
103 Fenobarbital Tab 30 mg Tablet - - - - - - 243 - - - -

LPLPO/KAB MBD Page 114


1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
104 Fenol Gliseron tetes telinga 10 % Botol 6 - 6 3 - 3 2,590 - 7,770 - 7,770
105 Fitomenadion ( Vit K1 ) Inj 10 mg/ml-1ml Vial - - - - - - 4,438 - - - -
106 Fitomenadion ( Vit K1 ) Tab Salut 10 mg Tablet 5,105 - 5,105 - - 5,105 890 - - - 4,543,450
107 Foley Catheter T. 6 Botol - - - - - - 30,000 - - - -
108 Foley Catheter T. 8 Buah - - - - - - 30,000 - - - -
109 Foley Catheter T.10 Buah - - - - - - 30,000 - - - -
110 Foley Catheter T.12 Buah - - - - - - 8,000 - - - -
111 Foley Catheter T.14 Buah - - - - - - 8,000 - - - -
112 Foley Catheter T. 16 Buah - - - - - - 8,000 - - - -
113 Foley Catheter T.18 Buah - - - - - - 8,000 - - - -
114 Foley Catheter T. 20 Buah - - - - - - 8,000 - - - -
115 Foley Catheter T. 22 Buah - - - - - - 8,000 - - - -
116 Foley Catheter T. 24 Buah - - - - - - 8,000 - - - -
117 Flagystatin Tablet Vagina Tablet - - - - - - 29,520 - - - -
118 Furosemida Inj i.v i.m 10 mg/ml Vial - - - - - - 1,850 - - - -
119 Furosemida Tab 40 mg Tablet 317 - 317 47 - 270 88 - 4,136 - 23,760
120 Formalin Cairan Botol - - - - - - - - - -
121 Gentamisin Inj 80 mg/ 2ml Ampul - - - - - - 3,854 - - - -
122 Gentamisin Salf Kulit 0,1 % Tube 10 - 10 - - 10 - - - -
123 Gentamisin Slufat Tetes Mata 0,3 % Botol - - - - - - 5,020 - - - -
124 Glimepride Tab 4 mg Tablet - - - - - - 273 - - - -
125 Gentian Violet Larutan 1 % Botol 17 - 17 2 - 15 5,200 - 10,400 - 78,000
126 Gipsonal Gipsum 4 Inchi Buah - - - - - - 28,500 - - - -
127 Gipsonal Gipsum 6 Inchi Buah - - - - - - 37,500 - - - -
128 Glibenclamide Tab Tablet 735 - 735 - - 735 720 - - - 529,200
129 Gliseril Guaiakolat Tab 100 mg/ Guafenisine Tablet 4,610 - 4,610 1,083 - 3,527 132 - 142,956 - 465,564
130 Glukosa Larutan Infus 5 % Steril Botol 20 - 20 - - 20 6,900 - - - 138,000
131 Glukosa Larutan Infus 10 % Steril Botol - - - - - - 6,840 - - - -
132 Glukosa Larutan Infus 40 % Steril Botol - - - - - - - - - -
133 Griseovulvin Tab 125 mg, Micronized Tablet 2,124 - 2,124 6 - 2,118 242 - 1,452 - 512,556
134 Handscoen S Pcs - - - - - - -
135 Handscoen M Pcs - - - - - - -
136 Handscoen L Pcs - - - - - - - - - -
137 Handscoen No. 6 Pcs - - - - - - - - - -
138 Handscoen No.7 Pcs - - - - - - 6,985 - - - -
139 Handscoen No.7,5 Pcs - - - - - - 6,985 - - - -
140 Hidroklorotiasida ( HCT ) Tab 25 mg Tablet - - - - - - 194 - - - -
141 Hidrokortison Krim 2,5 mg Tube 108 - 108 12 - 96 2,846 - 34,152 - 273,216
142 Ibuprofen Suspensi Botol - - - - - - 5,739 - - - -
143 Ibuprofen Tab 200 mg Tablet - - - - - - - - - -
144 Ibuprofen Tab 400 mg Tablet - - - - - - - - - -
145 Infusion Set Anak Pcs 150 - 150 - - 150 3,500 - - - 525,000
146 Infusion Set Dewasa Pcs 60 - 60 20 - 40 3,200 - 64,000 - 128,000
147 Isoniasid ( INH ) Tab 100 mg Tablet - - - - - - - - - -
148 Isoniasid ( INH ) Tab 300 mg Tablet - - - - - - 165 - - - -
149 Isosorbid Dinitrat Tab Sublingual 5 mg Tablet - - - - - - - - - -
150 Kalium Glukonat injeksi 10% (100mg/ml) Ampul - - - - - - 7,800 - - - -
151 Kalsium Laktat ( Kalk ) Tab 500 mg Tablet 1,705 - 1,705 185 - 1,520 62 - 11,470 - 94,240
152 Karbamasepin Tab 200 mg Tablet - - - - - - 241 - - - -
KAEN-3B Larutan infus (mengandung NaCl 1,75+KCL 1,5gr+ Na
153 Lactat 2,24 gr, Dextrose 27 gr) Botol - - - - - - 23,500 - - - -

154 Kapas Putih 1000 gr (Kapas Putih 1 Kg) Roll - - - - - - - - - -


155 Kantung Darah 250 cc Roll - - - - - - - - - -
156 Kapas Pembalut Absorben 250 Gram Roll - - - - - - 22,000 - - - -
157 Kapas Berlemak 500 mg Buah 7 - 7 1 - 6 16,500 - 16,500 - 99,000
158 Kasa Roll Panjang Besar 40x80 Cm Buah 2 - 2 - - 2 105,000 - - - 210,000
159 Kasa Kompres 40/40 Steril Buah 200 200 400 50 - 350 1,600 320,000 80,000 - 560,000
160 Kasa Pembalut Hidrofil Steril 16 cm x 16 cm Buah - - - - - - 8,000 - - - -
161 Kasa Pembalut Hidrofil Supergrade 40 cm x 16 cm Buah - - - - - - 36,960 - - - -

LPLPO/KAB MBD Page 115


1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
162 Kasa Steril 10 cm x 10 cm Buah 3,200 - 3,200 - - 3,200 - - - -
163 Keterolac Inj 30 mg Ampul - - - - - - 1,265 - - - -
164 Ketokonazole Tab 200 mg Tablet 1,170 - 1,170 40 - 1,130 311 - 12,440 - 351,430
165 Ketokonazole Krim Tube 50 - 50 - - 50 2,893 - - - 144,650
166 Kinina Dihidroklorida ( Kina ) Inj 25 %-2ml Ampul - - - - - - 7,440 - - - -
167 Kuinin Sulfat Tab 222 mg ( H2O ) (Qunine 222 mg) Tablet 300 - 300 - - 300 799 - - - 239,700
168 Klorpromasin HCL Tab Salut 25 mg Tablet - - - - - - - - - -
169 Klorpromasin HCL Tab Salut 100 mg Tablet 200 - 200 - - 200 179 - - - 35,800
170 Klorpromasin Inj 25 mg/ml-1ml Ampul - - - - - - 1,550 - - - -
171 Klorpromasin Inj 5 mg/ ml-2ml Ampul - - - - - - - - - -
172 Kodein HCL ( Kodeina ) Tab 10 mg Tablet - - - - - - 600 - - - -
173 Klip Plastik 7 x 10 cm Pak - - - - - - - - - -
174 Klip Plastik 8 x 5 cm Pak - - - - - - - - - -
175 Kertas pulvis Pak - - - - - - - - - -
176 Lancet blood Buah - - - - - - 623 - - - -
177 Lidokain Com, Inj Kombinasi Ampul 30 - 30 - - 30 1,433 - - - 42,990
178 Levofloksasin 500 mg Tablet - - - - - - 520 - - - -
179 Loratadine Tablet 10 mg Tablet - - - - - - 185 - - - -
180 Loperamide 10 mg Tablet - - - - - - -
181 Maxiflow Baby (Masker Oksigen) Pcs - - - - - - - - - -
182 Maxiflow Anak (Masker Oksigen) Pcs - - - - - - - - - -
183 Maxiflow Dewasa (Masker Oksigen) Pcs - - - - - - - - - -
184 Masker Botol 20 - 20 3 - 17 1,226 - 3,678 - 20,842
185 Masker Respirator N-95 Buah - - - - - - - - - -
186 Methilprednisolon Tablet 4 mg Tablet - - - - - - - - - -
187 Methilergometrin Maleat Inj 0,200 mg/ml-1ml Tablet - - - - - - 9,900 - - - -
188 Methilergometrin Maleat Tab salut 0,125 mg Tablet - - - - - - 185 - - - -
189 Meloxicam 7,5 mg Tablet - - - - - - - - - -
190 Meloxicam 15 mg Tablet - - - - - - 1,719 - - - -
191 Metformin HCL Tab 500 mg Tablet 1,220 - 1,220 10 - 1,210 138 - 1,380 - 166,980
192 Metformin HCL Tab 850 mg Tablet - - - - - - 168 - - - -
193 Metoklopramide Tab 10 mg Tablet 1,800 - 1,800 - - 1,800 117 - - - 210,600
194 Metronidasol Infus 500 mg/100 ml Botol 12 - 12 - - 12 11,547 - - - 138,564
195 Metronidasol Tab 250 mg Tablet - - - - - - 99 - - - -
196 Metronidasol Tab 500 mg Tablet - - - - - - 176 - - - -
197 Mikonazol Krim / Salf 2% ( Nitrat ) Tube - - - - - - 4,268 - - - -
198 Microlax Suppos Suppos - - - - - - - - - -
199 Mucus Extractor Buah - - - - - - - - - -
200 Natrium Diklofenak Tab 25 mg Tablet 3,150 - 3,150 210 - 2,940 163 - 34,230 - 479,220
201 Natrium Diklofenak Tab 50 mg Tablet 4,440 - 4,440 140 - 4,300 162 - 22,680 - 696,600
202 Natrium Klorida Larutan Infus 0,9% Steril Botol - - - - - - 6,410 - - - -
203 Nifedipin Tab 10 mg Tablet 110 - 110 20 - 90 219 - 4,380 - 19,710
204 Nistatin 100.000 IU/g Tab Vaginal Tablet - - - - - - 858 - - - -
205 Nistatin 500.000 IU/ Tab Salut Tablet - - - - - - 768 - - - -
206 NGT No. 6 Buah - - - - - - 22,000 - - - -
207 NGT.No. 8 Buah - - - - - - 22,000 - - - -
208 NGT.No.12 Buah - - - - - - 22,000 - - - -
209 NGT.No.14 Buah - - - - - - 22,000 - - - -
210 NGT.No.18 Buah - - - - - - 22,000 - - - -
211 Obat Batuk Hitam Botol 31 - 31 21 - 10 2,670 - 56,070 - 26,700
212 Omeprasol Tab 20 mg Tablet 266 - 266 111 - 155 150 - 16,650 - 23,250
213 Ondansetron Tablet 4 mg Tablet - - - - - - 1,090 - - - -
214 Obgyn Steril Handscoen Pcs - - - - - - 1,500 - - - -
215 Oralit/ Garam Oralit Saschet 1,700 - 1,700 - - 1,700 296 - - - 503,200
216 Objec Glass/Slide Pcs - - - - - - - - - -
217 Oxibiotic injeksi Vial - - - - - - - - - -
218 Oxitetrasikllin HCL Inj I.M 50mg/ml-10ml Vial - - - - - - - - - -
219 Oxitetrasikllin HCL Salep Kulit 3% Tube 2 - 2 - - 2 1,259 - - - 2,518
220 Oxitetrasikllin Salep Mata 1% Tube - - - - - - 2,600 - - - -

LPLPO/KAB MBD Page 116


1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
221 Oxitosin Inj 10 IU /ml-1ml (pitogin Injeksi) Ampul - - - - - - 3,020 - - - -
222 Oxyflow Baby Pcs - - - - - - - - - -
223 Oxyflow Anak Pcs - - - - - - - - - -
224 Oxyflow Dewasa Pcs - - - - - - - - - -
225 Pap Smer Kit S Pcs - - - - - - - - - -
226 Pap Smer Kit M Pcs - - - - - - -
227 Pap Smer Kit L Pcs - - - - - - -
228 Papaverin Inj 40mg/ml Ampul - - - - - - - - - -
229 Papaverin Tab 40 mg Tablet - - - - - - - - - -
230 Parasetamol Sirup 120 mg/ml Botol 296 - 296 214 - 82 1,252 - 267,928 - 102,664
231 Parasetamol Tab 500 mg Tablet 3,474 - 3,474 1,468 - 2,006 66 - 96,888 - 132,396
232 Pirantel Pamoat ( Pirantel ) Tab 125 mg Tablet 152 - 152 20 - 132 334 - 6,680 - 44,088
233 Piridoksin HCL ( Vit B6 ) Tab 10 mg Tablet - - - - - - 154 - - - -
234 Piroxicam Tab 10 mg Tablet 4,200 - 4,200 515 - 3,685 334 - 172,010 - 1,230,790
235 Piroxicam Tab 20 mg Tablet - - - - - - 244 - - - -
236 Plester 5 Yard x 2 Inch Buah - - - - - - - - - -
237 Pirasetam Tab 400 mg Tablet - - - - - - - - - -
238 Pirasinamida Tab 500 mg Tablet - - - - - - - - - -
239 Prednison Tab 5 mg Tablet - - - - - - 91 - - - -
240 Primakuin Tab 15 mg Tablet 2,000 - 2,000 - - 2,000 175 - - - 350,000
241 Primperan Injeksi Vial - - - - - - - - - -
242 Prokain Penisillin G Inj 3 Juta IU Ampul - - - - - - 22,880 - - - -
243 Propanolol HCL ( Propanolol ) Tab 40 mg Tablet - - - - - - 64 - - - -
244 Ranitidin Inj 25 mg/ml Vial - - - - - - 1,540 - - - -
245 Ranitidin Tab 150 mg Tablet 5,290 - 5,290 490 - 4,800 121 - 59,290 - 580,800
246 Retinol ( Vit A ) Kapsul Lunak 100.000 IU Kapsul 100 - 100 - - 100 355 - - - 35,500
247 Retinol ( Vit A ) Kapsul Lunak 200.000 IU Kapsul 750 - 750 - - 750 648 - - - 486,000
248 Retinol ( Vit A ) Kapsul Lunak 50.000 IU Kapsul - - - - - - - - - -
249 Ringer Laktat Larutan Infus Steril Botol 16 - 16 16 - - 7,150 - 114,400 - -
250 Rivanol Larutan (Etakridin ) 300 ml Botol - - - - - - 7,200 - - - -
251 Salbutamol Tab 2 mg Tablet - - - - - - - - - -
252 Salbutamol Tab 4 mg - - - 81 - - - -
253 Sefadroxil syrup 125mg/ml Botol - - - - - - 4,581 - - - -
254 Sefadroxil Kapsul 250 mg Kapsul - - - - - - - - - -
255 Sefadroxil Kapsul 500 mg Kapsul - - - - - - 587 - - - -
256 Setirizine Tab 10 mg Tablet - - - - - - 103 - - - -
257 Setirizine Suspensi Botol - - - - - - 3,192 - - - -
258 Semen Seng Fosfat Serbuk dan Cairan Botol - - - - - - - - - -
259 Sianokobalamin (Vit B12 ) Inj 500 mcg / ml-1ml vial 100 - 100 - - 100 1,335 - - - 133,500
260 Sianokobalamin ( Vit B12 ) Tab 50 mg Tablet 6,638 - 6,638 544 - 6,094 53 - 28,832 - 322,982
261 Seftriakson Inj 1 g/Vial vial - - - - - - 5,143 - - - -
262 Sefotaxim Inj 1 g/ Vial vial - - - - - - 7,700 - - - -
263 Simetidin Tab 200 mg Tablet - - - - - - - - - -
264 Simvastatin 5 mg Tablet - - - - - - -
265 Simvastatin Tab 10 mg Tablet 38 - 38 38 - - 110 - 4,180 - -
266 Siprofloxasin Tab 250 mg Tablet - - - - - - - - - -
267 Siprofloxasin Tab 500 mg Tablet 770 - 770 300 - 470 305 - 91,500 - 143,350
268 Scabimite Krim Tube - - - - - - 37,525 - - - -
269 Sofratule (Daryantull) Pcs - - - - - - - - - -
270 Sohobion Injeksi Ampul - - - - - - 4,740 - - - -
271 Silk Benang Bedah Sutera + Jarum No.2/0 75 cm Pcs - - - - - - 4,583 - - - -
272 Silk Benang Bedah Sutera + Jarum No.3/0 75 cm pcs - - - - - - 4,583 - - - -
273 Sofband Gips 6 Inch roll - - - - - - 37,500 - - - -
274 Sofband Gips 4 inch Roll - - - - - - 28,500 - - - -
275 Stik Glukosa Easy Touch Buah - - - - - - - - - -
276 Stik As. Urat Easy Touch Buah - - - - - - - - - -
277 Stik Kolesterol Easy Touch Buah - - - - - - - - - -
278 Tetrasiklin Kapsul 250 mg Kapsul - - - - - - 193 - - - -
279 Tetrasiklin Kapsul 500 mg Kapsul 1,750 - 1,750 - - 1,750 348 - - - 609,000

LPLPO/KAB MBD Page 117


1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
280 Terramycin Injeksi Vial - - - - - - 15,300 - - - -
281 Thiamin HCL / Monoitrat (Vit B1) Tab 50 mg Tablet 1,299 - 1,299 720 - 579 98 - 70,560 - 56,742
282 Thiamin HCL ( Vit B1 ) Inj 100 mg/ml-1ml Vial - - - - - - - - - -
283 Tranfusi Set (Blood Set) Pcs - - - - - - 3,600 - - - -
284 Tramadol injeksi Ampul - - - - - - - - - -
285 Urine Bag pcs 10 10 20 2 - 18 3,000 30,000 6,000 - 54,000
286 Ultra Sonic Gell Botol - - - - - - 12,854 - - - -
287 Under Pad 60 cm x 90 Steril With SAP Pcs - - - - - - - - - -
288 Ventolin injeksi (inhaler)